USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM

USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM PY4 ANNUAL REPORT: OCTOBER 2016 – SEPTEMBER 2017

Signing of the MOU between the USAID/Uganda Private Health Support Program and the Laboratory Network Uganda members to launch the Labnet Franchise, July 2017

October 30, 2017

This report is made possible by the support of the American People through the United States Agency for International Development (USAID). The contents of this report are the sole responsibility of Cardno Emerging Markets USA, Ltd. and do not necessarily reflect the views of USAID or the United States Government.

USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM PY4 ANNUAL REPORT: OCTOBER 2016- SEPTEMBER 2017

Submitted by: Cardno Emerging Markets USA, Ltd. Submitted to: USAID/Uganda Contract No.: AID-617-C-13-00005

DISCLAIMER

The author’s views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

USAID/Uganda Private Health Support Program

USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page i

Table of Contents

ACRONYMS ...................................................................................................................................................... IV

EXECUTIVE SUMMARY .................................................................................................................................... 1

KEY ACHIEVEMENTS IN YEAR 4 ......................................................................................................................... 1

CHALLENGES/MITIGATION EFFORTS ................................................................................................................. 3

HIGHLIGHTS FOR NEXT QUARTER’S PLANNED ACTIVITIES ............................................................................... 4

INTERMEDIATE RESULT (IR) 1: EXPANDED AVAILABILITY OF HEALTH SERVICES BY PRIVATE SECTOR PROVIDERS ..................................................................................................................... 6

1.1. STRENGTHENED SERVICE DELIVERY IN 71 PRIVATE SECTOR FACILITIES (54 PFPS, 17 PNFPS) ... 6 1.1.1. Support delivery of comprehensive quality services ............................................................ 6

1.1.1.1. Integrate HIV Testing Services (HTS) ..................................................................................................... 6

1.1.1.2. Integrate tuberculosis (TB)/HIV services……………………………………………………………….,7 1.1.1.3. Integrate voluntary medical male circumcision (VMMC) services ....................................................... 9 1.1.1.4. Provide family planning (FP) services ................................................................................................... 10 1.1.1.5. Integrate malaria services ....................................................................................................................... 12 1.1.1.6. Strengthen reproductive, maternal newborn and child health services ............................................ 12 1.1.1.7. Integrate prevention of mother-to-child transmission (PMTCT) services ......................................... 13 1.1.1.8. Strengthen access to essential medicines, test kits and supplies ..................................................... 15 1.1.1.9. Strengthen blood safety, injection safety and health care waste management .............................. 16 1.1.1.10. Strengthen comprehensive HIV/AIDS services for children and adolescents ............................... 17 1.1.1.11. Strengthen care and treatment of identified HIV positive clients in the private sector ................. 17 1.1.1.12. Strengthen laboratory and viral load monitoring for sustained viral load testing and viral suppression ............................................................................................................................................................. 19 1.1.1.13. Strengthen nutrition assessment counselling and support (NACS) and support for nutrition through the first 1,000 days ................................................................................................................................... 20

1.1.14. Quality improvement interventions....................................................................................... 20

1.2. STRENGTHENED SYSTEMS FOR SERVICE DELIVERY IN PRIVATE SECTOR FACILITIES .............................. 22 1.2.1. Strengthen skills of health workers .............................................................................................. 22 1.2.2. Support targeted continuing medical education (CME) ............................................................ 24 1.2.3. Support innovative approaches to task sharing and task shifting ........................................... 24 1.2.4. Strengthen policies, guidelines, standard operating procedures and job aids ...................... 24 1.2.5. Strengthen health management information systems .............................................................. 25

1.2.5.1. Identify and support health management information system (HMIS) focal persons ..................... 25 1.2.5.2. Strengthen weekly option B+ reporting ................................................................................................. 25

1.2.6. Strengthen Health Systems in the faith based sector ............................................................... 26 1.2.6.1 Improve the availability of human resources to support service delivery in the faith-based health sector ........................................................................................................................................................................ 26 1.2.6.2 Strengthen health leadership and governance in the private sector .................................................. 27 1.2.6.3. Improve health financing and finance management in the private sector ........................................ 27 1.2.6.4. Improve coordination with public facilities and other stakeholders at districts and national levels .................................................................................................................................................................................. 28

1.3. STRENGTHENED SUPPORT FOR ORPHANS AND VULNERABLE CHILDREN (OVC)................................... 28 1.3.1. Support performance based grants to Faith Based and Civil society organizations ............ 28 1.3.2: Households Economic strengthening activities ........................................................................ 28

1.3.2.1. Training of caregivers in business initiation, management and follow up support .............. 28 1.3.2.2. Training of Village Saving and Loan Association Leaders on Group Dynamics and Money management skills ............................................................................................................................................... 29 1.3.2.3. Household Vulnerability assessment. .............................................................................................. 29

1.3.3. Support to Apprenticeship and Vocational Training for out of school orphans and vulnerable children .................................................................................................................................... 29 1.3.4 Support Nutrition and Food Security Interventions .................................................................... 31 1.3.5. Support provision of Formal Education services. ...................................................................... 31 1.3.6. Support provision of health, water, sanitation and housing ..................................................... 32 1.3.7. Child Protection and Legal Support services ............................................................................. 32 1.3.8. Psycho Social Support to OVC and their Households .............................................................. 33 1.3.9. Increase access to HIV/AIDS Services ....................................................................................... 33 1.3.10. Promoting Private Sector Engagement .................................................................................... 33


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page ii

1.3.11. Mainstreaming of CBOs OVC activities .................................................................................... 33 1.3.11.1. Supporting children with disabilities: ................................................................................................... 33

1.4. SUPPORT BUSINESS STRENGTHENING AND INCREASE ACCESS TO FINANCE .......................................... 34 1.4.1. Expand financial outreach through DCA banks ......................................................................... 34 1.4.2. Expand Financial Outreach through Non-DCA Banks .............................................................. 36 1.4.3. Provide technical assistance to DCA banks and borrowers (actual and potential) .............. 37 1.4.4. Supporting USAID in the identification and recommendation of a third health DCA bank partner ......................................................................................................................................................... 38 1.4.5. Provide business strengthening support .................................................................................... 39

1.5. PROGRAM TRANSITION PLAN IMPLEMENTATION ...................................................................................... 40

INTERMEDIATE RESULT (IR) 2. INCREASED AFFORDABILITY OF PRIVATE HEALTH SERVICES AND PRODUCTS ......................................................................................................................... 41

2.1. REDUCING THE PRICES OF HEALTH PRODUCTS AND SERVICES ............................................................... 41 2.1.1. Provide access to income generating opportunities for HIV/AIDS peer support groups ..... 41 2.1.2. Facilitate dialogue between MOH and private health sector to rationalize financing for health .......................................................................................................................................................... 42 2.1.3. Supporting the passage of the health financing strategy and national health insurance bill ..................................................................................................................................................................... 43 2.1.4. Exploring the possibility of a drug benefit plan as an interim step for national health insurance .................................................................................................................................................... 44

2.2. INCREASING HEALTH SERVICES AND MEDICINES PRICING TRANSPARENCY .......................................... 44 2.2.1. Conduct a pharmacy and drug shop census in Kampala to augment ongoing KCCA facility census ......................................................................................................................................................... 45 2.2.2. Conduct an Awareness Campaign on Rational Use of Medicines and Disseminate recommended EMHSL Commodity Prices ............................................................................................ 46 2.2.3. Support pooled procurement for private health providers ........................................................ 47 2.2.4. Disseminating the professional fee guidelines ........................................................................... 47

2.3. LIMITING FINANCIAL BARRIERS TO ACCESSING HEALTH SERVICES .......................................................... 48 2.3.1. Promote use of information and communication technology (ICT) in health......................... 48 2.3.2. Promoting health insurance and health savings with VSLA groups ....................................... 48 2.3.3. Document maternal health voucher program in Kiruhura district to demonstrate success of privately financed self-sustaining voucher to delivery critical health services .................................. 49

2.4. PROMOTING PREVENTATIVE CARE AMONGST WORKPLACE BASED CLIENTS AND HEALTH PROVIDERS ... 50 2.4.1. Health talks amongst private health insurers’ and health management organizations’ membership to encourage health seeking behaviour .......................................................................... 50 2.4.2. Updating and Enforcing National referral guidelines ................................................................ 50

INTERMEDIATE RESULT (IR) 3. IMPROVED QUALITY OF PRIVATE HEALTH SECTOR FACILITIES AND SERVICES ......................................................................................................................... 52

3.1. IMPLEMENT SQIS AND OTHER CONTINUOUS QUALITY IMPROVEMENT MECHANISMS .............................. 52 3.1.1. Roll out of the self-regulatory quality improvement system (SQIS) ........................................ 52 3.1.2. Link the Health as a Business (HaaB) network facilities to SQIS ........................................... 52 3.1.3. Support facility self-assessments ........................................................................................... 52 3.1.4. Maintain USAID/ASSIST continuous quality improvement (CQI) approaches and scale up to other Program activities ....................................................................................................................... 53 3.1.5. Establish a laboratory network ..................................................................................................... 53 3.1.6. Conduct DQA across all Program health areas ......................................................................... 54 3.1.7. Conduct Site service quality assessments using SIMS tool .................................................... 54

3.2. IMPLEMENT SQIS AND OTHER CONTINUOUS QUALITY IMPROVEMENT MECHANISMS .............................. 54 3.2.1. Resume updating the council acts through a performance based grant ............................... 54 3.2.2. Assist the councils to design and establish a web-based platform ......................................... 55 3.2.3. Support continuous professional development .......................................................................... 55 3.2.4. Assist Kampala City Directorate of Health Services to harmonize and field test a uniform application for facility licensure ............................................................................................................... 55 3.2.5 Assist Kampala City Directorate of Health Services and Environment to conduct a private provider census ......................................................................................................................................... 56


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page iii

3.3. ASSIST PRIVATE SECTOR REPRESENTATIVES TO PROMOTE STANDARDS OF CARE AMONG PFP

PROVIDERS ....................................................................................................................................................... 56 3.3.1. Strengthen capacity of UHF and other private sector associations to provide services valued to their members ........................................................................................................................... 56 3.3.2. Support UHF to implement strategic plan................................................................................... 56 3.3.3. Strengthen private sector engagement with MOH .................................................................... 57 3.3.4. Advance the formation of a public-private sector dialogue forum ........................................... 57

3.4. IMPLEMENT PPPHS THAT STRENGTHEN PRIVATE SECTOR CAPACITY TO DELIVER QUALITY SERVICES . 57 3.4.1. Develop the Ministry of Health PPPH Node’s capacity ............................................................ 57 3.4.2. Build support for the MOH to implement PPPs in health ......................................................... 58 3.4.3. Form a steering committee and conduct a private sector assessment .................................. 58 3.4.4. Build the MOH’s PPPH pipeline ................................................................................................... 59 3.4.5. Strengthen PPPH coordination at both the central and district level ...................................... 59

GRANTS MANAGEMENT AND PERFORMANCE ................................................................................................... 60

ANNEX 1: PHS PERFORMANCE INDICATOR TABLE, OCTOBER 2016–SEPTEMBER 2017 ........ 64

ANNEX 2: SUCCESS STORY ........................................................................................................................ 72

Table of Figures

Figure 1. HIV Yield by entry point ...................................................................................................... 6

Figure 2. HIV Testing Achievement versus Target ......................................................................... 6

Figure 3. Treatment Outcome of Patients Registered 12-15 Months Earlier ............................. 7

Figure 4. VMMC Services ................................................................................................................... 9

Figure 5. Family Planning Uptake.................................................................................................... 10

Figure 6. FP Methods and Procedures by Trainees ..................................................................... 11

Figure 7. IPT Uptake .......................................................................................................................... 12

Figure 8. Causes of Perinatal Deaths ............................................................................................. 13

Figure 9. HIV Care (Achievement versus Targets) ....................................................................... 18

Figure 10 ART: Newly initiated and Current on ART .................................................................... 18

Figure 11 Option B+ health Facility weekly reporting rates ......................................................... 26

Figure 12. Centenary DCA Utilization as % of Total Guarantee Amount as of 30 September 2017 ...................................................................................................................................................... 34

Figure 13: Ecobank DCA Utilization as a % of Total Guarantee Amount as of 30 September 2017 ...................................................................................................................................................... 35

Figure 14: Structure of the DFCU DCA .......................................................................................... 38

Figure 15: GIS map for the northern part of Nakawa sub-division, Kampala ........................... 45

Figure 16: Proposed National Referral Chain and Flow .............................................................. 50

Figure 17: OVC approved grants for the period versus funds disbursed .................................. 61

Figure 18: Care and treatment grantee approved grants versus funds disbursed .................. 62

Figure 19: PFP grantee average percentage performance for the period October - September 2017 ...................................................................................................................................................... 62

Figure 20: PFP grantee funds disbursement against budget status for the period October - September 2017 ................................................................................................................................. 63


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page iv

Acronyms

AE Adverse Event

ANC Antenatal Care

ART Antiretroviral Therapy

BDS Business Development Service

BTL Bilateral Tubal Ligation

CARDNO Cardno Emerging Markets USA, Ltd.

CD4 Cluster of Differentiation 4

CEDO Child Rights Empowerment and Development Organization

CME Continuous Medical Education

CMS Credit Management System

COP16 Country Operational Plan 2016

CSO Civil Society Organization

DCA Development Credit Authority

DFCU Development Finance Company of Uganda

DHIS2 District Health Information System 2

FGD Focus Group Discussion

FP Family Planning

HaaB Health as a Business

HBB+ Helping Babies Breathe Plus

HIPS USAID/Uganda Health Initiatives for the Private Sector Project

HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome

HMIS Health Management Information System

HRH Human Resources for Health

HSS Health Systems Strengthening

HTC HIV Testing and Counselling

ICOBI Integrated Community Based Initiatives

IDI Infectious Disease Institute

IGA Income Generating Activity

IHA Insight Health Advisors

IHSU International Health Sciences University

INH Isoniazid

IPT Isoniazid preventive therapy

IPTP Intermittent Preventive Treatment of Malaria in Pregnancy

IRCU Inter-Religious Council of Uganda

JMS Joint Medical Stores

KCCA Kampala City Council Authority


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page v

LARC/PM Long-Acting Reversible Contraception/Permanent Methods

MAUL Medical Access Uganda Limited

MCH Maternal Child Health

MEEPP Monitoring and Evaluation of the Emergency Plan Progress

MGLSD Ministry of Gender, Labor and Social Development

MOH Ministry of Health

MSH Management Sciences for Health

MSI Marie Stopes International

NACS Nutrition Assessment Counseling and Support

NDA National Drug Authority

Open MRS Open Medical Records System

OVC Orphans and Vulnerable Children

OVC MIS Orphans and Vulnerable Children Management Information System

PEPFAR President’s Emergency Plan for AIDS Relief

PFP Private for Profit

PHP Private Healthcare Provider

PHS USAID/Uganda Private Health Support Program

PLHIV People Living with HIV

PMTCT Prevention of Mother-to-Child Transmission

PNFP Private Not-For Profit

PPP Public Private Partnerships

PPPH Public Private Partnerships for Health

PPPH TWG Public Private Partnerships for Health Technical Working Group

PSA Private Sector Assessment

QA Quality Assurance

QI Quality Improvement

RDQA Routine Data Quality Assessment

SIMS Site Improvement through Monitoring Systems

SME Small and Medium-Sized Enterprises

SMC Safe Male Circumcision

SQIS Self-Regulatory Quality Improvement System

STI Sexually Transmitted Infection

TA Technical Assistance

TB Tuberculosis

TT Tetanus Toxoid

TWG Technical Working Group

UCBHCA Uganda Community Based Healthcare Association


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016- September 2017 Page vi

UHF Uganda Healthcare Federation

UHMG Uganda Health Marketing Group

UMA Uganda Manufacturers Association

UOMB Uganda Orthodox Medical Bureau

UPMA Uganda Private Midwives’ Association

USAID United States Agency for International Development

VMMC Voluntary Medical Male Circumcision

VSLA Village Savings and Loan Association

WAOS Web-Based HIV/AIDS Ordering and Reporting System


USAID/Uganda Private Health Support Program: Year 4 Annual Report: October 2016 - September 2017 Page 1

Executive Summary

The USAID/Uganda Private Health Support Program (PHS) is USAID’s flagship program in the private

sector in Uganda. The PHS Program leverages the private sector’s strengths while addressing

longstanding concerns about capacity, quality, and interests. Cardno Emerging Markets USA, Ltd.

(Cardno) leads this five-year program, supported by three subcontractors: Banyan Global, the Infectious

Diseases Institute (IDI), and Insight Health Advisors (IHA).

The PHS Program aims to strengthen, organize, and mobilize the private sector to provide Ugandans

with the option of obtaining high-quality health services from private providers. The goal is to improve

the credibility and cohesiveness of the private sector and expand the capacity of those providers. The

focus is to provide technical expertise, enhance quality standards, improve access to capital, support

accreditation, and provide leadership in the private sector. To achieve this, the Program has three main

intermediate results: (1) Expanded availability of health services by private providers; (2) Increased

affordability of private health services and products; and (3) Improved quality of private health sector

facilities and services.

Since August 1, 2014, PHS has expanded to support access to HIV/AIDS services through the Private

Not for Profit (PNFP) providers previously supported by USAID through the Inter- Religious Council

of Uganda (IRCU). Beginning October 1, 2016, PHS has integrated Private for Profit (PFP) sector

interventions – designed to strengthen regulatory systems, improve reporting and financing, and build

public private partnerships (PPP) – into the faith based sector, strengthening faith based sector health

systems to expand the availability of and access to quality and sustainable essential health, as well as

HIV/AIDS services. Such interventions include the adoption of self-regulatory quality improvement

standards (SQIS), access to finance initiatives like the Development Credit Authority (DCA) and

support to private sector umbrella institutions. To build a strong foundation for sustained scale-up of

integrated health and HIV/AIDS services for People Living with HIV/AIDS (PLHIV), PHS has

continued to strengthen PFP and PNFP health systems.

This report summarizes strategies and activities implemented during Program Year 4 (Quarter 4 and

Annual) while highlighting PHS achievements during the reporting period.

Key Achievements in Year 4

51,730 men received TT vaccination and were circumcised representing an achievement of 114%

of the annual target (45,448). Of those circumcised, 28,229 (55%) were within the priority age pivot

of 15-29.

94.9% (334,886/ 352,704) of the targeted individuals received HTS services of whom 3% (10,228)

were identified to be HIV positive, and of those, 8,162 individuals (80%) were linked to care.

Overall, we linked 8,162 clients to care, 150% of the annual target (5,430).

39,319 (11,494, PFP 27,825 PNFP) PLHIV were active in care (Pre-897, ART-38,422) translating

into 97.8% of PLHIV on ART. During the same time 1,318 (488 PFP, 830 PNFP) new PLHIV were

enrolled into care while 1,989 clients were initiated on ART ( 661 PFP, 1,328 PNFP). Of these 741

(254 PFP, 487 PNFP) 55.8% were male.

22,884 of 38,422 PLHIV on ART had a viral load done, with 91.5% showing virological

suppression.

39,319 (pre-ART 897, ART-38,422) HIV clients in care, 38,082 (97%) (9,768 PFP, 28,314 PNFP)

were screened for TB. Of those that were screened, 310 (0.8%) (Pre-126 & ART-184) were

diagnosed with TB and 182 (58.7%) started on anti TB treatment.

78% (19,175/24,600) of pregnant women had received at least 2 doses of Intermittent Preventive

Therapy (IPT) to prevent malaria in pregnancy.

876 (259 PFP, 617 PNFP) HIV exposed infants (HEI) received DNA PCR (1st DNA 525 (167 PFP,

358 PNFP), and 2nd DNA PCR 351 (92 PFP, 259 PNFP)). Of the samples that were sent to UNHLS,

for 1st DNA PCR, 58 % were drawn from children < two months of age (an improvement from the



previous quarter at 48.2%). Of all the returned results 14 babies were found to be positive (1st DNA

PCR 9 (1 PFP, 8 PNFP) and on 2nd DNA PCR 5 (4 PFP, 1 PNFP)) yielding a MTCT rate of 4%

across facilities. 29 health workers from 18 health facilities were trained in elimination of mother-

to-child HIV transmission course (EMTCT).

54,070 (36,273 ART clients and 17,797 non –ART clients at OPD) were assessed for nutritional

status. Of these 948 (1.8%) were malnourished with 378 newly malnourished. 430 of the total

malnourished cases received nutrition supplements and therapeutic feeds through site based

nutrition units or referral to other nutrition centres. In addition, 2,526 pregnant and lactating mothers

(8.5% HIV positive) were reached with maternal nutrition counselling and infant feeding

counseling. As a result of the counseling, 131 HIV positive exposed infants exclusively breastfed

for six months and out of those breastfed 90 (68.7%) HIV positive exposed infants breastfed up to

1 year.

Trained 245 health workers in long-term acting reversible contraceptives, and trained 17 medical

officers in permanent methods in Quarter 4.

Rolled-out the consolidated guidelines for HIV prevention and treatment in 57 (80.3%) of supported

private health facilities.

Conducted a perinatal death audit in 22 health facilities that reported a neonatal death and supported

facilities to institutionalize perinatal death review committees. In addition, mentorship and coaching

in neonatal resuscitation, partograph use and helping mothers survive techniques were integrated in

this activity.

In the PY October 2016-September 2017, the Program supported 46,572 OVC (31,898 PNFP and

14,674 PFP) from 13,993 households.

Validated and finalized the Comprehensive Health System Strengthening Needs Assessment

(HSNA) conducted in Quarter 3. At the same time PHS developed Human Resource Management

manuals for the bureaus, and modeled the Human Resource Management manuals for Hospitals

and Charters for Health units. These policies and charters will ensure the existence of codified

approaches for human resource management in Uganda’s faith based health sector/network. PHS

developed Board Governance manuals for the 4 Bureaus, and modeled the manuals for Hospitals,

Charters for Hospitals and lower health facilities. PHS developed Finance Management manuals

for the 4 Bureaus, and modeled these manuals for Hospitals and health units. A total of 69 Finance

Officers, In-Charges and members of the Management Committees of 30 Health Facilities under

UPMB and UOMB were trained in Finance Management and Internal Controls.

Finalized and completed the Uganda Private Health Sector Assessment (PSA). The PSA explores

policies supporting governance in the private health sector; health financing related to the private

health sector; human resources for health; size and scope of the private health supply chain; and

private sector delivery of key health services including HIV/AIDS, and maternal and child health.

A road map dubbed the “Private Sector Blue-print” was developed to guide public-private

interactions and discussions within the sector.

Continued to support the passage of the health financing strategy and national health insurance bill.

The Program developed an action plan for the private health insurance industry (including the

Health Management Organizations (HMO’s), to engage with the Ministry of Health (MOH) while

the proposed National Health Insurance Scheme (NHIS) is being implemented.

Provided actuarial consultancy services to select private health insurance providers and HMO’s in

Uganda to enable them to develop a health insurance product that they can market to individuals

and integrate with the proposed National Health Insurance Scheme (NHIS) once various MOH

initiatives on costing are concluded. A key outcome was an understanding of the minimum benefit

package an average Ugandan can afford in private health insurance.

Worked with the National Drug Authority (NDA) and the Kampala City Council Authority (KCCA)

to conduct the pharmacy and drug shop census (with GIS mapping) in all the five Divisions of

Kampala. Findings indicated that the number of both pharmacies and drug shops expanded



dramatically in the last six years. However, this rapid growth is a missed opportunity to increase

access to key public health services through private pharmacies and drug shops.

Provided the Washington-based USAID/DCA management office support in identifying and

recommending a third health DCA bank. Efforts have been positive and a new five-year health

DCA agreement has been concluded with DFCU Bank Limited for a US$5 million loan portfolio

guarantee, with a special focus on leasing of medical equipment.

Supported efforts to translate the Public Private Partnerships for Health (PPPH) technical working

group to a committee that doubles as a public-private sector dialogue forum. The dialogue forum

will focus on health financing and Public Private Partnerships (PPP) opportunities and create a

shared understanding of the role of the private health sector in Uganda.

Conducted a training on basic concepts on PPPH’s and on regional experiences in PPP’s for

representatives from the MOH, different social franchises, professional associations, Medical

Bureaus, and civil society organizations. The Program also continued to develop PPPH

implementation guidelines and procedures for the MOH’s PPPH Node. The Program validated the

draft MOH PPPH strategy and started on developing an Implementation Plan to operationalize the

PPPH strategy. The Program will provide technical assistance to annualize and cost the strategy.

During the year, the Program also trained 23 MOH/private sector staff as Trainers of Trainees in

PPPH.

335 facilities were enrolled in the self-regulatory quality improvement system (SQIS) platform. Out

of these, PHS supported 219 facilities to self-assess, using the online SQIS platform in 33 districts.

Health facilities can now monitor their quality improvement progress through comparing and

analyzing the different series of assessments they submit in the system. Health workers will also be

able to better prepare for pre-licensing inspections. In addition, during the year, the Program, in

partnership with the IntraHealth’s Capacity Project, printed and disseminated over 2,000 SQIS

toolkits. Health facilities can now access a toolkit from the councils at the time of registration. This

will enable facilities to understand the requirements at registration.

Held transition meetings with health facilities and incoming implementing partners (IP’s). These

meetings were attended by facility staffs, representatives of incoming IP’s, and Program staff. IPs

included IDI, Makerere University Walter Reed Program and Rakai Health Sciences Program. PHS

engaged in the transition of four OVC partners.

Reviewed and updated strategic plans for the Uganda Private Midwives’ Association (UPMA),

Uganda Community Based Healthcare Association (UCBHCA) and the Uganda Private Health

Training Institutions Association (UPHTIA). Once the strategic plans are completed, the

associations will be better positioned to fulfill their mandates and raise extra resources from

alternative sources, including donor organizations, so they can become sustainable. The Program

also provided support in legal, coordination, and logistical services to private health sector

associations. The Program 1) reviewed and improved their existing legal documents, 2) assisted

them in registering appropriately to engage in pooled procurement activities, and 3) trained their

members on pooled procurement, member recruitment, and ordering guidelines.

Faciliated formation and operation of a private-for-profit medical diagnostic laboratory network in

collaboration with the Uganda Medical Laboratory Technology Association (UMLTA). Since this

network will follow a franchise network strategy, the Program supported UMLTA adopt the Labnet

name and branding strategy with the goal of achieving a uniform, community-wide East African

identity and quality standards for qualified, independent medical laboratories.

Challenges/Mitigation Efforts

There was a frequent stock out of SMC commodities (SMC kits, anesthetics, and TT vaccines) and

cotrimoxazole. The program addressed this by carrying out internal redistribution among supported

private sector facilities and also borrowing from other implementing partners.

The supply of TB commodities to the private sector is not well streamlined for pediatric regimens

and isoniazid for prophylaxis. These commodities are distributed through National Medical Stores



(NMS) and the majority of private sector sites do not have accounts with NMS. The Program has

engaged respective, district TB logistics focal persons to design a rational approach to the supply

of TB commodities to ensure no stock outs for the private sector. Going forward in Year 5, the

Program will roll out the TB Web-based Ordering System (TWOS) in the private facilities to

improve TB logistics management.

Learned that the lack of a secondary market for medical equipment makes our partner banks

reluctant to accept such equipment as collateral, creating an obstacle to equipment financing. Crown

Healthcare is willing to work with the PHS Program to provide a buy-back guarantee for medical

equipment loans, giving the DCA banks extra assurance. However, the condition is that equipment

must be returned in reasonable condition and have been fully serviced by Crown Healthcare; the

value must be above a minimum. The Program will formalize through a memorandum of

understanding and to be signed in Quarter 1 of Year 5. The Program will also assist Crown

Healthcare in drafting partnership proposals for other interested financial institutions.

Ecobank DCA continues to underperform. The causes of the slow utilization of Ecobank DCA has

been repeatedly documented over the previous fiscal years. For administrative reasons, USAID has

decided to leave the guarantee in place, but asked the Program not to dedicate further resources to

technical assistance for Ecobank DCA at this time.

Supported efforts towards designing and approving the PPPH Node charter. However, finalization

of this work was deferred until the PPPH structure and TWG composition is aligned to the law.

Recommendations from the analysis of existing structures set out in the PPPH policy proposed an

expansion in the PPPH structure within MOH. Therefore, in order to develop a standard Node

charter it required alignment between the proposed new PPPH structure to the PPP law. This activity

is ongoing and will be concluded during the next quarter.

Out of the 335 facilities currently registered with the SQIS digital platform, 219 were self-assessed

by the end of the year. Some facilities had poor internet access, while others failed to self-assess on

their own, despite attending trainings. The Program has printed tools for facilities with limited

internet access. These same facilities will receive additional technical support to self-assess. The

Program will continue to work with an IT firm to trouble shoot the system and make it user friendly.

Highlights for Next Quarter’s Planned Activities

USAID/Uganda Private Health Support (PHS) Program is in the final phase of the project. During the

subsequent two quarters, PHS will consolidate efforts to respond to the three Intermediate Results. The

Program’s activities will focus on: finalizing key Program Year 1 through 4 interventions, consolidating

achievements, institutionalizing capacity in both public and private organizations responsible for

ensuring quality in the private health sector, transitioning interventions that have shown promise to key

private health sector associations, and disseminating various research findings and recommendations

from prior conducted studies. Key activities will be transitioned to USG IPs by March 2018 to ensure

continuity of services. Illustrative activities will include:

Support 12 facilities (3 attained, 4 scale-up aggressive, 5 scale-up saturated) in a total of seven

districts to provide comprehensive HIV/AIDS prevention, treatment, support, and care services.

Continue to provide a comprehensive Voluntary Medical Male Circumcision (VMMC) package at

five PNFP facilities in five districts (1 attained, 2 scale-up aggressive, 2 scale-up saturated).

Hold stakeholder meetings, engage the incoming IPs and health facilities to enable a seamless

transition process. Support Delivery of Comprehensive services through the Private sector

including Reproductive, Maternal Newborn and Child Health (RMNCH) Services, Family planning

(FP), Malaria and Nutrition services.

Strengthen health management information systems (MIS) and OVC MIS.

Provide grants to 42 community-based organizations (32 PNFP, 10 PFP) to support vulnerable

children along the four COP 2017 OVC thematic areas: Healthy, Stable, Safe and Schooled. While

at the same time implementing priority activities that will include: graduation of OVC households



with reduced vulnerability, and transfer of OVC Programs in scale up-districts to other PEPFAR

OVC mechanisms.

Continue technical assistances (TA) support to Centenary Bank and Ecobank for the ongoing DCAs

as well as provide TA support to DFCU Bank to utilize the new DCA. PHS will conduct a survey

to measure impact of A2F on health outcomes of DCA borrowers and develop a “How-To of a

Successful DCA in Health”, demonstrating that the DCAs have made a difference.

Provide business development services (BDS) to selected healthcare businesses and carry out an

end-line survey to measure the impact of the HaaB II BDS support on health outcomes of

participating HCBs.

Roll-out implementation of HSS activities targeting all four medical bureaus and 134 health

facilities, as informed by the HSS needs assessment findings and recommendations, and medical

bureau work plans.

Continue with efforts to develop a Drug Benefit Plan as an interim step for NHIS.

Provide TA to UHF to advocate for NHIS.

Continue to disseminate Professional fee guidelines amongst private health providers using their

respective associations.

Continue to support the formation and operation of Labnet Uganda following a franchise network

strategy.

Support Health Facilities in implementing SQIS and other continuous quality improvement

mechanisms.

Disseminate findings of the Private Sector Assessment.

Create an inventory of all PPPHs and formalize all the PPPs within the KCCA area.



Intermediate Result (IR) 1: Expanded Availability of Health Services by Private Sector Providers

1.1. Strengthened Service Delivery in 71 Private Sector Facilities (54 PFPs, 17 PNFPs)

This section of the report (Task 1.1 – 1.6) details achievements from both PHP and PNFP private sector

services during the reporting period. In Year 4, the Program supported strengthening of services

delivery at all Program supported PFP and PNFP facilities. During the same time, the Program worked

to consolidate and sustain access to high impact HIV prevention and comprehensive, quality HIV and

AIDS care, support and treatment services through Program supported facilities. Key activities focused

on clinical and financial management training, access to finance, and service delivery grants for

HIV/AIDS and orphans and vulnerable children (OVC) support, as well transition and implementation.

A total of 71 facilities (54 PFPs, 17 PNFPs) and 45 OVC partners (36 PNFP, 9 PFP) received support

from the Program.

1.1.1. Support delivery of

comprehensive quality

services

The program strengthened service

delivery at all supported PHP and

PNFP health facilities in line with the

90- 90 -90 strategy for controlling the

HIV/AIDS epidemic. The PHS partner

health facilities provided

comprehensive services in HIV testing

services (HTS), Family Planning (FP),

TB, Malaria, Maternal and

Newborn/Child Health (MNCH), and

Voluntary Medical Male Circumcision

(VMMC).

1.1.1.1. Integrate HIV Testing

Services (HTS)

During the reporting period, 1,258

health workers were trained on the

revised HTS guidelines with emphasis

on key areas including test and treat,

reduced age of consent, retesting

before ART initiation, and focus on

HIV testing quality and strategies to

reach hard-to-reach and undiagnosed

populations. As a result, in Quarter 4

86,630 individuals were reached and

given same day results. Of these 2,463

were positive translating into positivity

rate of 3%. Of those found to be

positive 84% were linked into care

during the reporting period. A total of

5,924 were tested as couples of whom

389 (6.6%) were concordant positive

and 207 (3.5%) had discordant results.

50.1% individuals tested were males of

Figure 1. HIV Yield by entry point

Figure 2. HIV Testing Achievement versus Target

0.4%

2.6%

3.0%

4.0%

10.0%

24.0%

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%

VMMC services

In patient department

Other PITC

VCT

Index client testing

TB clinic

H I V Y I E L D B Y E N T R Y P O I N T

88

17

6

17

63

52 2

64

52

8 35

27

04

79

76

6 15

60

16 2

46

98

7 33

48

86

O C T - D E C 1 6 J A N - M A R 1 7 A P R - J U N E 1 7 J U L Y - S E P T 1 7

HIV TESTING SERVICES

Target Clients rec'd HTC

Linear (Target ) Linear (Clients rec'd HTC)



whom 2.1% were identified to be living with HIV. 67.2% of the males tested were 20 years and above

with a positivity rate of 2.9%.

During Program Year 4, 334, 886 (94.9%) of the annual target of 352,704 individuals received HTS

services. Three percent (10,228) were identified to be HIV positive. Of those found to be HIV positive,

overall 8,162 (80%) were linked into care. The yield at different entry points was as follows during the

reporting period; Index client testing (10%) and TB clinic (24%). In-patient department (2.63%), VCT

(4%), VMMC services (0.4%) and other PITC (3%), see Figure 1.

By the end of Year 4, the highest yield for positives was through the TB clinic while VMMC yielded

the lowest number of positives. Going forward, boys and adolescents shall be screened and only high-

risk individuals will be tested for HIV. The program performed fairly well in providing targeted HTS

for men and this is attributed to the implementation of mixed methods to reach men such as using male

champions and opinion leaders, emphasisingthe benefits of early enrollment in care, and conducting

community health campaigns using a multi-disease approach. Other strategies included creating male

friendly HTS at facility and community level as well as prioritizing couple testing at PMTCT sites.

Although the performance on linkage rate was below the expected performance of 90%, there was

progressive improvement across the 4 quarters, (63% Quarter 1; 85% Quarter 2; 78% Quarter3; and

85% Quarter 4) and this is largely attributed to the mentorship and support of facilities on the new MOH

standard operating procedures for linkage and referral.

1.1.1.2. Integrate tuberculosis (TB)/HIV services

By the end of the Program Year4, out of the total 39,319 (pre-ART 897, ART 38,422) HIV clients that

were in care, 38,082 (96.9%) (9,768 PFP, 28,314 PNFP) were screened for TB. Of those that were

screened, 310 (0.8%) (Pre-ART 126 & ART 184) were diagnosed with TB. Of those that were

diagnosed with TB, 182 (58.7%) were started on TB treatment. Out of those started on treatment 180

(97.8%) (20 PFP, PNFP 160) were HIV/TB co-infected. For patients who had started TB treatment over

the last 12-15 months, 441 (135 PFP, 306 PNFP) of TB/HIV co-infected patients and completed six

months course of treatment had the

following outcomes: 167 (46 PFP,

121 PNFP) contributing to 37.9%

completed their treatment, 121 (33

PFP, 88 PNFP) contributing

27.4%, 28 died (8PFP, 20PNFP), 2

(1 PFP, 1 PNFP) failed on

treatment and 61 were lost to

follow up while 62 were not

evaluated, see Figure 3.

Of 502 (131 PFP, 371 PNFP) TB

cases including newly registered

TB cases and relapse TB cases,

377 (92 PFP, 285 PNFP) (75.1%)

were tested for HIV. Of these 146

(32 PFP, 114 PNFP) contributing

to 38.7% were TB/HIV co-

infected. Of these 141 (30 PFP,

111 PNFP) (96.6%) were given Cotrimoxazole and 142 (29 PFP, 113 PNFP) (97.3%) were started on

ART.

This improved performance, which resulted from the strengthened capacity building interventions,

through onsite based TB trainings, mentorship and coaching. Emphasized TB cases through

identification at all entry points using index client model, use of QI approaches in improving

documentation, and use of data to monitor TB indicators at screening, linkage, initiation on treatment

and follow up to ensure retention and good outcomes. The areas of focus included; proactive

identification of children with probable TB using the intensified TB case finding form (ICF),

Figure 3. Treatment Outcome of Patients Registered 12-15 Months Earlier

Cured, 121, 27%

Completed, 167, 38%

Died, 28, 6%

Failure, 2, 1%

Lost to Followup, 61,

14%

Not Evaluated,

62, 14%



management of pediatric TB, use of Gene expert (indications, sample collection, packaging and

transportation and interpretation of results), infection prevention and control, HMIS support, and

facilities understanding the supply chain management for TB commodities. Engagement of District

TB/Leprosy focal persons (DTLS) improved access to anti-TB drugs and supplies and used gene Xpert

testing services through utilization of the hub system by Program supported private facilities.

Fewer cases of TB continue to be identified in the private sector due to a number of challenges

including: stock outs and inconsistency in the supply and access to Anti-TB drugs, Gene-Xpert

machines, and challenges with cartridges at the district hubs. Similarly, IPT coverage at the partner

health facilities was low due to insufficient stock of Isoniazid at the respective districts. Therefore,

children were being prioritized for IPT at most health facilities leaving out other eligible clients such as

those who completed TB treatment and newly TB diagnosed clients, which accounted for 17%

coverage.

In the Program Year 5, PHS will continue to work closely with NTLP, Regional and District TB and

Leprosy Supervisors (DTLS) to strengthen integration of TB services at all service delivery entry points.

Program will focus on the scale-up of TB intensified case finding, IPT accessibility, including capacity

building, infection prevention and control of TB and initiation of TB treatment for all confirmed cases.

All HIV positive clients will continue to be screened for TB at every ART clinic visit, and all TB

patients will be screened for HIV co-infection. They will be managed appropriately according to the

recommended guidelines. The program will support Health facilities in accessing Anti TB drugs,

including isoniazid for prophylaxis, reagents for ZN and facilitate the availability Gene-Xpert testing

for TB facilities at district hubs.



1.1.1.3. Integrate voluntary medical male

circumcision (VMMC) services

In Program Year 4, PHS supported 21

VMMC sites (11 PNFP and10 PFP) in 12

districts across the country. During the

Quarter 4, 16,525 males received TT and

were circumcised which is 151% of the

expected quarterly target (10,948). Of

these, 52% (8,616) are from the 15-29 age

group. A total of 51,730 men received TT

and were circumcised representing an

achievement of 114% of the annual target

(45,448). Of those circumcised, 28,229

(55%) were within the priority age pivot of

15-29. As part of VMMC services, HIV

testing was offered to the clients and a total

of 48,717 (96%) of males tested for HIV

and received results. Of those tested and

given results, 245 (0.5%) tested HIV

positive and were linked to care. A total of

2,308 men were not tested for HIV because

these were boys age 10-14 had low

exposure to HIV risk and when applied to

the eligibility screening tool, they were

found ineligible.

46,565 (91%) males were followed up

within 48 hours, 36,102 (71%) within 7

days, and 10,722 (21%) beyond 7 days.

The Program maintained good

performance on follow up rates especially

at 48 hours and 7 days and this was due to

intensified follow up by partner facilities.

The facilities sustained dedicated SMC

teams to conduct follow up in the

community and also emphasized to clients the benefits of returning post circumcision for review. In the

coming year, the program will continue to focus on improving performance for beyond 7 days follow

up through implementation of innovative strategies such as working with mobilisers to follow up with

clients until the completion of SMC cascade and use of phone calls.

Results from follow up indicate that 271 advance events (AEs) were encountered of which 261 were

moderate and 10 were severe and were all post-operative and managed successfully. The 10 severe

advance events were encountered at Ishaka Adventist hospital (1), Mengo hospital (3), Span Medicare

(3), Kiko HC III (1) and Kisiizi hospital (2). They comprised of excessive bleeding, identified post-

operatively and controlled during exploration, excessive hematoma that required surgical re-

exploration, anaphylaxis to local anesthetic agent, and infection that required intramuscular antibiotic

therapy. The Program will continue to support facilities to reduce adverse events (AE) through

intensified post circumcision client follow up and to manage mild AEs before they develop into

moderate AEs, and conducting regular AE audits to establish likely factors responsible for the AE

occurrences.

PHS performed well during the year surpassing Country Operational Plan 2016 (COP 16) targets. This

is attributed to Program intensifying follow up and circumcising clients that had initially received TT1

but had not returned. Other strategies implemented included reassessing and determining individualized

VMMC site capacity against performance and putting in place tailored mechanisms that enabled sites

to achieve high results. Strategies included mobilization through radio programs, peer-to-peer

Figure 4. VMMC Services

57238,302

20475

16,525

11,362 13,242

15,712

10,948

0

5000

10000

15000

20000

25000

QTR1 QTR 2 QTR 3 QTR 4NO

OF

MA

LES

CIR

CU

MC

ISED

SMC QUARTELY TARGETS AND OUTPUTS

VMMC OUTPUTS

Clients circucmcised per Qtr Quartely target

5,420

14,613

35,205

51,730

11,362

22,724

34,086

45,448

OCT-DEC 16 JAN-MAR 17 APR-JUNE 17 JULY-SEPT 17

VMMC OUTPUTS OCT 16-SEPT 2017

Clients Circumcized Total Target



mobilization especially for the older boys and using role models in the community as champions for

circumcision were employed. PHS continued to conduct continuous quality improvement approaches

and provided onsite coaching and mentorship at all private sector VMMC sites. This was coupled with

routine data validation activities and results indicate that the data reported was of good quality. Through

AIDSFree, the Program continued to work with Green Label waste management company and the SMC

waste was adequately managed.

1.1.1.4. Provide family planning (FP) services

The Program continued to support 62 facilities (47 PFP, 15 PNFP) to provide family planning (FP)

services. Through capacity building of health workers (training, mentorship, and coaching), provision

of family planning (FP) commodities and data management tools, private health facilities provided FP

services at both PNFP and PFP sites. Health workers were mentored to integrate FP into other existing

services like HIV/ART clinics, VMMC in addition to the traditional MNCH services and emphasis put

on FP, prong 2 (eMTCT) in preventing unwanted pregnancy among women living with HIV.

As a result of the above support, in Quarter 4, a total of 8,643 new acceptors (7,353 PFP, 1,290 PNFP)

accessed FP services translating into 24,695 (82.3%) new acceptors of the annual target during program

year 4. Higher number of attendance at the PFP sites points to the flexible working hours, availability

of method mix at the facilities, skilled personnel and willingness of the service providers to provide

modern methods of contraception. During the reporting period, of all new acceptors, 17.6% were

adolescents 10-19 years old, 41.0% were 20-24 years old, and 41.4% ≥ 25 years old. 7,423 (6,621 PFP,

802 PNFP) individuals returned for revisit/supply visit. Of the new acceptors, a total of 2,596 (1785

PFP, 811 PNFP) received long-acting reversible contraceptives (IUD’s and Implanon) and 105

individuals received permanent contraception (Bilateral tubal ligation) which was higher 31%

compared to 11% in the previous quarter. 80.3% (57/71) of the targeted service delivery points offered

family planning services by the end of Quarter 4. 300 (177 PFP, 123 PNFP) new users were HIV

positive. Over the year, performance verses target is as shown in the Figure 5 below.

Figure 5. Family Planning Uptake

3581

6,5885,883

86437500 7500 7500 7500


# o

f n

ew

FP

acc

ep

tors

Time

FP uptake

New FP acceptors Total Target



In line with MOH national Implementation

Plan for LARC/PMs (2017-2020) strategic

objectives, in Quarter 4 the Program set out

to address skills gap among health workers

in providing long-term reversible

contraceptives including PPIUD. The

increase in the number of LARC and

permanent methods noted in Quarter 4, is

attributable to 10 day simulation and

practicum training in LARC and PM that

was carried out. 245 health workers were

trained from at least 46 private health

facilities. Medical Eligibility Criteria

(MEC) wheels to support health workers in

selecting the best family planning choice

based on pre-existing medical conditions

were provided to each participant.

During the training, participants conducted

a total number of 1,711 procedures as a

part of the practicum. Figure 6 below

shows the number of FP methods and

procedures done by type. Participating

health facilities were provided with some

equipment for IUD insertion, implant

removal, vasectomy sets, and BTL sets,

comprehensive family planning manuals to

support service delivery, and CPDs upon

return to their facilities

Figure 6. FP Methods and Procedures by Trainees

Going forward, in order to improve access to quality of FP services, PHS will strengthen the skills of

health workers in long term/permanent methods of FP through facility based post-training follow up

and mentorship, and provision of FP commodities and supplies in partnership with UHMG. The

420

565

377

216

129

4

IUD Insertion

Implanon Insertion

Jadelle Insertion

Implant removal

IUD removal

BTL

0 100 200 300 400 500 600

Number of different FP methods and procedures done by trainees during field practicuum

Medical officers training in LARC/PM.



Program will also support the use of consumption based supply system, integration of FP services, and

will promote principles of voluntarism and client’s right for free informed choice.

1.1.1.5. Integrate malaria services

In Quarter 4, 5,417 (2,599 PFP, 2,818 PNFP) women received two or more doses of IPTP for malaria

during pregnancy. By the end of year 4, 78% (19,175/24,600) of pregnant women received at least two

doses of Intermittent Preventive

Therapy (IPT) during antenatal care

visits using Sulfadoxine and

Pyrimethamine to prevent malaria.

A total of 365/219 (167%) health

workers were trained and/or

mentored in Integrated Management

of Malaria (IMM) and IPTP as

follows: 80 health workers were

trained in IPT, 31 in IMM while 258

health workers were mentored

during post training follow up and

mentorship in integrated

management of malaria including

IPTP across all facilities. Areas that

were covered during the mentorship

included: pregnant women eligible

for IPT (SP) and that included IPT1,

IPT2, IPT3 and IPT4 as per the new guidelines given after 12 weeks of pregnancy at least 4 weeks apart.

The rationale for use of cotrimoxazole as IPT and prevention of other opportunistic infections for

pregnant women living with HIV, evaluation of patients with fever, and performing rapid diagnostic

testing (RDT’s) for malaria. Sessions also included evaluation of a patient with a negative blood slide

or RDT; treatment of uncomplicated malaria with ACT’s and complicated malaria using artesunate;

practical reconstitution of artesunate; management of malaria in pregnancy; management of fever after

malaria treatment; implementation of the test and treat policy in management of malaria; and the review

of documentation pertaining to malaria. A high training target was attained and progressive increment

in the number of pregnant women initiated on two or more doses of IPT was noted at each Quarter

(See Figure 7). The overall target was not achieved due to stock outs of sulfadoxime and

pyrimethamine (fansidar) and Antimalarial commodities for PNFP, while PHP are not availed free

from warehouses. The Program will continue to lobby for malaria commodities like RDTs, combined

artemisinin based antimalarial therapies (coartem), fansidar, and LLITN through partnership with

districts.

1.1.1.6. Strengthen reproductive, maternal newborn and child health services

During the quarter, a total of 8,418 women (3,065 PFP, 5,353 PNFP) attended the first antenatal care

(ANC) visit. 91.7% received iron and folic supplementation, which is 1.2 times higher than the previous

quarter.

During Year 4, all women received information and counseling to ensure safe pregnancy and delivery

as well as counseling on family planning. 2,510 (1,016 PFP, 1,494 PNFP) received Vitamin A

supplementation in maternity while 1,687 (748 PFP, 939 PNFP) received Vitamin A supplementation

during the postnatal period.

Figure 7. IPT Uptake

4361 4,5114,886

5417

6150 6150 6150 6150


IPT UPTAKE

IPT2 Uptake Total Target



In maternity wards, partographs were used to monitor delivery, outcome of labor and performing active

management of third stage of labor (AMTSL). Neonatal resuscitation was performed for infants with

poor Apgar scores. At birth, all 7,198 babies were provided with newborn care that included: airway

assessment, breathing and circulation assessment, thermal protection (skin to skin), cord care (health

workers encouraged to use chlorhexidine recommended by the new guidelines in essential newborn

care (ENBC)), exclusive breastfeeding initiation, infection prevention including eye care (tetracycline

eye ointment) and immunization. Facilities that reported at least one neonatal death earlier in the year

had a perinatal death review/audit carried out. Health facilities were supported in setting up and

institutionalizing perinatal death review committees through other existing committees for QI and

MDRC, mentorship and coaching in partograph use, neonatal resuscitation using simulators, essential

newborn care (KMC, cord hygiene, infection prevention and control including early initiation of breast

feeding), and helping mothers survive. Techniques

focused on preventing primary post-partum hemorrhage,

one of the leading causes of maternal death in Uganda,

and improvement in documentation. Facilities were given

the BABIES matrix information to improve processes

and systems for better perinatal outcomes.

Figure 8 shows the common causes of perinatal mortality

identified during the perinatal death audit exercise in the

private sector. Birth asphyxia was notably the leading

cause of death, similar to findings in other related

literature. Going forward, health workers will be

supported further in newborn resuscitation, early referral,

ensuring presence of a skilled health workers at the time

of birth through mentorship and coaching, prevention

through ANC health talks to avoid delays in seeking care,

and delays in reaching the health facility by having a birth

plan. Emphasis will be placed on improving documentation to minimize missing outcomes.

During the year, PHS trained health workers in Helping Babies Breath Plus and Reprocessing of

Resuscitation Equipment. Basic neonatal resuscitation equipment that included Ambu-bags and

penguin suckers were distributed to all facilities that participated in the training. In addition, PHS

obtained and reprinted IEC materials from MOH and PATH International, which included learners work

books for essential newborn care, helping babies breathe, and a handbook on reprocessing of neonatal

resuscitation equipment. The project trained 59 health workers from 27 health facilities in helping

mothers survive bleeding after birth and pre-eclampsia and eclampsia to improve skills of the health

service providers in the private sector.

Going forward, PHS will train private midwives under UPMA on how to manage the common leading

causes of death among women and newborns through the following courses; helping mothers survive

bleeding after birth, helping mothers survive eclampsia/pre-eclampsia, helping mothers survive

obstructed labor and helping babies breathe plus (HBB+).

1.1.1.7. Integrate prevention of mother-to-child transmission (PMTCT) services

During the reporting period, the Program supported the provision of prevention of mother-to-child

transmission (eMTCT) services at 56 health facilities (41 PFP, 15 PNFP) along the ANC period, labor

and delivery and post-natal care cascade.

Antenatal Care: ANC package was delivered to all pregnant women regardless of HIV status. At the

ANC point of care, a total of 8,418 pregnant women (3,065 PFP, 5,353 PNFP) attended ANC for the

first time during the current pregnancy. Of these, 11.4% of the pregnant women were adolescents 10-

19 years old, 31.7% 20-24 years old and 56.9% were ≥25 years old. Those newly tested for HIV during

ANC were 7,623 (2,695 PFP, 4,928 PNFP), of these, 163 (83 PFP, 80 PNFP) were found to be positive

translating into a positivity rate of 2% in ANC. Of those testing positive, 151 (93%) (72 PFP, 79 PNFP)

were initiated on lifelong ART (Option B+) and cotrimoxazole. 1,706 (447 PFP, 1259 PNFP) pregnant

Figure 8. Causes of Perinatal Deaths

Fresh still birth, 61,

39%

Macerated still birth, 41, 26%

Early neonatal

death, 45, 29%

Missing, 10, 6%



women were re-tested for HIV during subsequent ANC visits, of these, 57 pregnant women were found

to be positive translating into 3.3% of women testing HIV positive.

Maternity: In Quarter 4 7,198 (2,279 PFP, 4919 PNFP) deliveries were conducted across program

supported facilities. 12.7% of deliveries were to adolescents 10-19 years old, 30.0% to 20-24 years old

and 56.3% of the deliveries were to ≥25 years old. Those newly tested for HIV during labor and delivery

were 828 (310 PFP, 518 PNFP), of these, 21 (5 PFP, 16 PNFP) were found to be positive. Re-testers

were 1,773 (497 PFP, 1,276 PNFP). Of those re-testing during labor and delivery, 30 (14 PFP, 16 PNFP)

were found to be positive. A total of 51 (19 PFP, 32 PNFP) women were found to be positive during

labor and delivery and only 17 were initiated on ART. This is attributed to denial to accept results during

this period and loss to follow up upon discharge.

Postnatal Care: 8,857 women attended post-natal clinic (2,388 PFP, 6,469 PNFP). 10% of women

attending post-natal clinic were adolescents 10-19 years old, 32.5% were 20-24 years old and 57.4% of

these were ≥25 years old. Those newly diagnosed with HIV during postnatal care were 22 (2 PFP, 20

PNFP). 13 (0 PFP, 13 PNFP) tested positive on a retest. 35 tested positive, 26 were initiated on ART.

Early Infant Diagnosis: During the quarter, 876 (259 PFP, 617 PNFP) HIV exposed infants (HEI)

received DNA PCR testing using dry blood spots at Program supported facilities (1st DNA 525 (167

PFP, 358 PNFP), 2nd DNA PCR 351 (92 PFP, 259 PNFP). Through the hub system, samples are sent to

Uganda National Health Laboratory Services (UNHLS) for testing and sent back to the facilities. Of the

samples that were sent to UNHLS, for 1st DNA PCR, 58 % were drawn from children < two months of

age, an improvement from the previous quarter (48.2%). Of the samples dispatched, 61.2% were

returned to the sending facilities. During the quarter, a number of facilities reported challenges with

non-return of results up to a period of 4 months, which was reported by Kisiizi Hospital. Of all the

returned results 14 babies were found to be positive, 1st DNA PCR 9 (1 PFP, 8 PNFP) and 2nd DNA

PCR 5 (4 PFP, 1 PNFP) yielding a MTCT rate of 4% across facilities.

At 18 months of age, 264 HEI (38 PFP, 226 PNFP) had a rapid HIV confirmatory test done, 4 HEI were

found to be positive during the quarter (3 PFP, 1 PNFP) while 260 HEI were discharged with negative

results. During the reporting period, 379 HEI (78 PFP, 301 PNFP) were initiated on Cotrimoxazole,

287 (65 PFP, 222 PNFP) 75.7% of whom were initiated at less than two months of age.

In Quarter 4, 29 health workers from 18 health facilities were trained in elimination of mother-to-child

HIV transmission course (eMTCT) that covered

the following areas: chronic care, including

ART to HIV infected pregnant and lactating

women, care and treatment for HIV exposed and

infected infants and children; management of

logistics for implementation of Option B+ at the

facility; correct documentation and submission

of PMTCT Option B+ reports; and

demonstrated to participants the rationale for

HIV Exposed Infant (HEI. Conducted eMTCT

cohort monitoring, analysis, and utilization of

cohort data to enhance quality delivery of HEI

and eMTCT program. Inset is a group

discussion during eMTCT course during which

participants had a hands-on data abstraction and

cohort analysis of HEI data.

Going forward, efforts will be made to support

health workers improve on identification of HEI, and removal of samples and dispatch to UNHLS to

reduce sample rejection. The Program will also work with MOH UNHLS to improve on the TAT of

results. In line with COP17 and the 90-90-90 targets, PHS will focus to reach all pregnant and

breastfeeding women, initiate them on lifelong ART (Option B+), and improve mother baby care

retention with good outcomes.

PMTCT training for health workers



1.1.1.8. Strengthen access to essential medicines, test kits and supplies

PHS conducted logistics supportive supervision, performance assessment and mentoring of health

facility staff in 71 sites. The Program reviewed the ordering, storage, distribution and dispensing

practices at each of the facilities and reviewed electronic copies of facility ARV orders over the last two

quarters to determine their completeness, correctness of submitted information and adherence to current

guidelines when enrolling new clients. During these visits gaps in the management of commodities were

identified and together with facility personnel solutions were derived and improvement targets set.

Some of the gaps identified included: poor coordination in the supply of TT vaccines, TB and FP which

caused frequent stock outs especially of TB commodities and excess stocks especially of FP

commodities at the facilities, inappropriate storage practices, inadequate space particularly in PFP sites

and lack of skills amongst health workers for appropriate stock control and logistics management, no

use of stock books even when available and a number of sites did not have direct access to DHIS 2.

Hence, sent and scanned copies of orders to JMS inceased the probability of error and delays in

submission of orders. Strengths noted include facilities had the knowledge and skills to determine which

medicines to order using the dispensing logs, and had access to computers and connectivity.

Going forward, the Program has put in place a number of interventions including: supervision, and

performance assessment and mentoring approach to improve logistics indicators. The approach will

involve quarterly visits to assess logistics indicators with identification of gaps and challenges which

will be addressed through managerial and educational strategies. Ongoing job mentorship and coaching

will continue to be carried out to address the identified gaps. The Program procured and distributed

cabinets for 10 PFPs that were constrained by storage space. In addition, standard operating procedures

were printed and distributed to staff for future reference, while performing their logistics function.

Subsequent follow up of supported facilities will monitor progress on set indicators.

Roll out of the Web Based ARV Ordering Systems (WAOS): The program further worked with JMS to

support the acquisition of user rights and conducted on-the-job training for all staff involved in the

ordering of ARVs using the WAOS. Currently all sites have been given WAOS user rights and it is

expected that in the coming ordering cycle they will directly input their orders into DHIS 2. This will

reduce delays in entering orders into DHIS 2 and the web-based system will help highlight and correct

obvious errors in filling order forms before they are sent to the warehouse.

Streamlining TB Supply Chain Systems: The Program noted that TB medicines and supplies were the

most frequently stocked out items in the private sector. The main cause of this is the uncoordinated

ordering and supply systems which do not prioritize the private sector. The Program has continued to

advocate for a more streamlined supply system for TB medicines in the PNFP and PFP sectors. At

medicine procurement and supply chain TWG meetings, the problem of frequent stock out of TB

A before and after picture of ARVs storage at Chandaria Medical Clinic. To the left is part of the lab cupboard within the laboratory being used used to keep ARVs. To the right is the new cabinet



medicines will be addressed. There are also plans to support sites to access the TB web-based ordering

system in order to create awareness of the demand of these commodities in the private sector.

During the reporting period, PHS worked with the warehouses, Ministry of Health (NTLP, UNHLS,

ACP) to ensure a stable and constant supply of ARV’s, test kits, SMC kits and related supplies and FP

commodities medicines to minimize stock outs and reduce the risks of disrupting service delivery due

to stock outs during PHS transition process. PHS developed a warehousing and distribution system to

hold the excess stock and supplies them to the sites on a bi-monthly order and delivery schedule to

prevent expiration and pilferage.

In order to improve hygiene, Program is addressing challenges in handling waste and improving

infection prevention and control. The program procured and distributed 90 heavy duty bins and 201

hand washing stations to all sites.

1.1.1.9. Strengthen blood safety, injection safety and health care waste management

At the beginning of Year 4, the Program developed an environmental mitigation monitoring plan to

ensure safe disposal of healthcare waste in order to not negatively affect aquatic and terrestrial fauna,

flora, human health, and water sources during the delivery of integrated comprehensive health services.

By the end of the year, the Program had conducted a training of 35 health workers from 25 health

facilities in 14 districts. During this training, health workers were equipped with knowledge and skills

in healthcare waste management, sharps/injection and blood safety to improve management of

healthcare waste at Program supported health facilities. During the training, trainees developed a

healthcare waste management plan, observed safe disposal of injection/sharps, learned about blood

safety, and how to separate, transport, and dispose of waste according to the recommended guidelines.

In addition, hand washing and personal protective equipment demonstrations were conducted. As part

of integrated facility based mentorship activities, facilities will continue to be supported in

implementing their healthcare waste management plan once developed, infection and prevention

practices at the different service delivery points and implementation of 5S as a QI tool.

In addition, during the year, 31 laboratory staff and 16 laboratory/facility support staff involved in health

care waste management (Cleaners and Courier) from selected health facilities attended a five day

training in Biosafety. The overall aim for this training was to impart skills and knowledge in bio risk

and biosafety management to enable behavioural change and attitude towards health facility in risk

reduction measures and security. A facility based post training follow up and mentorship was conducted

for all health workers, reaching 102 health workers during that period.

Trainer guiding participants on how to don and doff PPE. On the right an ongoing biosafety course at Infectious Diseases Institute



1.1.1.10. Strengthen comprehensive HIV/AIDS services for children and adolescents

During the reporting period, 11,585 children <15 year were tested for HIV, 90 (0.8%) were found to be

positive and out of these 81 (90%) were linked and enrolled in care. In total 2,093 (636 PFP, 1,457

PNFP) children < 15 years are in care.

In PY4, Program in collaboration with the

MOH conducted adolescent HIV care,

treatment and trainings, reaching 76 health

workers in 36 health facilities. The

training aimed at enhancing health care

providers’ knowledge, skills, attitudes and

general competencies to provide quality

and comprehensive HIV care, treatment

and support services to adolescents living

with HIV. Healthcare providers were

trained to counsel and provide

psychosocial support, HIV care &

treatment and identify, link and refer

adolescents for comprehensive care and

support. Desk Job aids were provided,

including supported sites, to establish

adolescent friendly corners, especially in

high volume sites.

Post training follow up mentorship

and coaching were conducted for

pediatrics and Adolescent PITC at

the supported health facilities,

focusing on the strengthening

integration of adolescent services at

all entry points, identification of

HIV positive children and

adolescents and linking them to care

and treatment. Emphasis was placed

on high yield entry point testing, use

of the screening tool to identify

high-risk children particularly in

OPD, implementation of the Know

Your Child Status Days, use of the

family tracking tool to identify

positive children of index clients, providing age appropriate counselling and service delivery in friendly

settings. Adolescent index client model was emphasized to track and identify those that missed

enrollment into care. The Program supported health facilities to make use of adolescent HIV data

through analysis of viral load test data to identify challenges of unsuppressed viral load and work with

the adolescent peer groups, care takers, guardians and parents to support tracking for retention in care

and adherence to HAART to achieve viral suppression.

1.1.1.11. Strengthen care and treatment of identified HIV positive clients in the private sector

During the reporting period, a total of 39,319 (11,494 PFP 27,825 PNFP) PLHIV were active in care

(Pre-897, ART-38,422) translating into 97.8% of PLHIV on ART. Of those in care, 37,356 (9,647 PFP,

27,709 PNFP) received cotrimoxazole or dapsone for prophylaxis.

The Program enrolled 1,318 (488 PFP, 830 PNFP) new PLHIV into care. Of these 1,105 (428 PFP, 677

PNFP) (83.8%) of these received cotrimoxazole and dapsone for prophylaxis. 1,989 new clients were

initiated on ART ( 661 PFP, 1328 PNFP) with the new test and treat policy explaining the high number

HIV positive children in session at St. Francis-Buluba

Trainees' practicum at Jinja RRH Adolescent Clinic and TASO Jinja



of those started on ART compared to the previous quarter and of these 741 (254 PFP, 487 PNFP)

translating to 55.8% were male.

Figure 9. HIV Care (Achievement versus Targets)

Figure 10 ART: Newly initiated and Current on ART

Of the 1,294 clients at the end of the twelve month cohort analaysis 1,036 (366 PFP, 670 PNFP) (80.1%)

were still alive at the end of period after initiation of ART. This is lower compared to the target and a

drop in performance compared to last quarters, attributed to client death 20(1.5%), stopping treatment

48 (3.7%), lost 65 (5.0%) and lost to follow up clients 170 (13.1%) especially in the mobile populations

among clinic offering care to plantation workers.

1,450

2,930

4,5025,820

1,373

2,745

4,121

5,491


Newly enrolled into HIV Care

# newly enrolled Target-Newly enrolled

39,626 38,684 39,976 39,31945,863

52,05758,251

64,445


Clients in HIV Care

# on Care Target-Care

1,2881,647 1,933

1,989

34,842 36,241 37,85438,422

0

20,000

40,000

60,000

O C T - D E C 1 6 J A N - M A R 1 7 A P R - J U N E 1 7 J U L Y - S E P T 1 7

ART

# newly initiated on ART

# currently receiving ART



The Program conducted onsite based rollout

trainings of the revised consolidated HIV

guideliens 2016 for HIV prevention and

treatment in the 57 (80.3%) out of 71 facilities

reaching 1,258 health workers. The health

facilities also received the job aids on

consolidated guidelines and during the training

were supported in the ordering of LPR/r pellets

for children under 3 years of age as per

guidelines.

In year 5, the Program will complete the

facilitty based trainings for remaining 14

(19.7%) facilities and will conduct follow up

assessment and mentorship in all the 71 health

facilities. Thereafter the Program will continue

to support comprehensive HIV ART follow up mentorship and coaching in 12 health facilities to ensure

all pre-ART clients are initiated on ART, viral load monitoring carried out, follow up and retention of

all clients including mother-baby pairs.

1.1.1.12. Strengthen laboratory and viral load monitoring for sustained viral load testing and viral

suppression

With support from the MOH Central Public Health Laboratory (CPHL) and in partnership with districts

through engagement and working closely with District Laboratory Focal Persons (DLFPs), all PHS

supported sites offering ART services were linked to the hub system to improve laboratory testing and

monitoring among PHLIV. Health facilities trained in viral load monitoring during year 4 have been

supported by availing viral load test kits, viral load laboratory request forms, dispatch envelopes and

supported on sample packaging and transportation through the hub system to maintain the integrity of

samples during the sample transportation process and avoid sample rejection at the hub. As a result of

the above support in Quarter 4, samples that were collected from Program supported private health

facilities had a rejection rate of 1.98%,, 5721 of clients on ART received a viral load test of whom

91.3% showed evidence viral suppression with viral copies of <1000 copies per ml. During the year,

PHS had a total of 38,422 PLHIV on ART, 22884 had a viral load done, with 91.5% had virological

suppression. Distribution by age and gender during the annual period < 15years (males 75.3%, females

80.1%) while those > 15 years had suppression rates (91.6% males, 92.1% females)

Despite progress over time, VL monitoring was affected by long turnaround time (TAT) of test results

and non-return of test results. Other limitations included failure of hub riders to pick up viral load

samples, and limited knowledge/skills of health workers in supporting non-virally suppressed clients

with intensive adherence counselling as well as facilities not ordering test kits directly from UNHLS,

which is encouraged, for purposes of sustainability. Capacity building efforts to improve on laboratory

quality service delivery have been carried out such as laboratory quality management improvement

system, laboratory logistics management, and bio risk and biosafety course for technical and support

staff aimed at reducing risk in the lab and improving efficiency.

Going forward, roll out of the revised 2016 HIV consolidated guidelines and mentorship will enable

health workers implement changes in the guidelines like test and treat strategy and intensive adherence

counselling that aim at increasing both coverage and suppression. PHS will continue working with the

districts through the DLFPs, CPHL, and avail new MOH tools like the VL suppression register, and

implement the scale up package aimed at improving coverage.

Trainees watching the LPV/r pellet video at FHRC -Kiruhura



1.1.1.13. Strengthen nutrition assessment counselling and support (NACS) and support for

nutrition through the first 1,000 days

Integrated nutritional assessment counseling and support (NACS) continued to be part of routine

services in HIVART care accorss all Program health facilities. During the reporting period, the Program

supported trainings and mentorship to strengthen integration of nutrition services in the 17 PNFP health

facilities. A total of 34 frontline health workers were trained in NACS, health facilities were supplied

with nutrition job aides, equipment for basic anthropomentric measurements like mid upper arm

circumference tapes of all age ranges, revised and updated MOH nutrition data collection and reporting

tools. Post training follow up mentorship, coaching, supporting linkage and referral of malnuourished

clients to health facilities that access ready to use therapautic feeds (RUTF) in other regional activated

and accredited RUTF sites like regional referral hospitals and district based hospitals.

Integrated nutrition mentorship and coaching as part of routine health facility techncial support

strengthened health workers knowledge and skills to routinely screen, assess, link, document and report

clients reached with nutrition services. Task shifting and multi tasking was emphasized so as to

strengthen integration of nutrition services at all entry points like OPD, YCC, MCH and TB and

HIV/ART clinics. Health facilities were supported to include QI nutrition indicators to monitor changes

in nutrition assessment, counselling and support including linkage to therapeutic feeds.

During the reporting period, a total of 54,070 (36,273 ART clients and 17,797 non –ART clients at

OPD) were assessed for nutritional status using color coded MUAC tapes and Height/Length for age

z-scores. Of these 948 ( 221 PFP, 727 PNFP) translating into 1.8% were found to be malnourished. Of

these, 132 (14%) with moderate acute malnutrition (MAM), 284 (30%) had acute malnutrition without

odema (SAM) while 39 (4%) had severe acute malnutrition with odema. The newly malnourished cases

were 378, and of these 156 ( 41.3%) were HIV positive. 430 of the total malnourished cases received

nutrition supplements and therapeutic feeds through site based nutrition units or referral to other

nutrition centres. Out of those who received thereapeatic feeds 142 ( 33%) were HIV positive. In

addition 2,526 pregnant and lactating mother were reached with maternal nutrition counseling and out

of theses 216 (8.5%) were HIV positive and 2,659 received infant feeding counselling of which 150

(5.6%) were HIV positive. During the reporting period 131 HIV exposed infants exclusively breastfed

for 6 months, 90 (68.7%) infants breastfed up to 1 year.

However, full integration of NACS services across all entry points and health facilities remained

inadequate due to lack of well caliberated weighing scales, lack of height boards and infatometer, lack

of access to thereaupeutic foods, weak referral and linkage systems to public health facilities, and lack

of affordable transport for the referred clients. Community nutrition approaches have also not been well

integrated as a way to use positive deviation in addressing malnutrition through intra-housed learning

and farming to improve household food and nutrition security.

In PY5, the Program will continue to promote task shifting and encouraging multi-tasking through

mentorship, coaching and supporting monthly CMEs to improve health workers appreciation and

understanding NACS. Use of nutrition tools and data, strengthen collaborative linkage and referral with

other nutrition centers like referral hospital and district thereapeutic hospitals and HCIVs, improving

documentation, reporting and data use will be used to improve nutrion services. For community

nutrition, the Program will to train community nutrition workers and nutrition mother mentors to

support community nutrition education, community food nutrition garden and preperation, assessment

and referral of malnuourished to nutrition center, and positive deviant homes or nutrition mother

mentors.

1.1.1.14. Quality improvement interventions

In PY4, the Program continued to conduct monthly QI mentorship and coaching to strengthen the

functionality of health facility Quality Improvement Teams (QITs) and Work Improvement teams

(WITs) in all the Program ART and VMMC sites. In coordination with USAID/ASSIST, PHS continued

to engage national, regional, and district based QI coaches to support integration and scale up of quality

improvement interventions to supported sites. In partnership with the Program, USAID ASSIST



continued to support monthly onsite VMMC QI mentorship and coaching in 9 health facilities and the

Program scaled up the best QI practices across all other 13 VMMC implementing health facilities.

However, the challenges of the national, regional and districts QI coaches not accepting the preferred

mode of support as per the USAID Local Development Partner Group schedule of allowances (2017),

the Program innovatively came up with mechanism to support continuity in strengthening the scale up

integration of QI approaches across all Program partners and health facilities. These approaches

included training Program staff and Research Assistant in QI, SQIS and SIMS and also soliciting a

competent registered consultancy firm to support the Program techncial team.

During the reporting period, the Program in collaboration with USAID/ASSIST and MOH organised

VMMC QI experience sharing and learning session for all the 21 VMMC implementing sites as a

platform for sharing implemented QI projects and showed how these change packages caused

improvement at their respective health facilities. Three health workers from each health facility VMMC

QI team participated in the learning session. During the learning sessions new updates and guidelines

on TT and VMMC implementaion packages, along with best practices were shared with partner sites.

Post learning session follow up mentorhsip, coaching, and support focused on reviewing

implementation of learned best practices, realigning change packages and QI projects, functionality

and use of data by the QIT/WIT, and health facility in general for decision making towards improving

VMMC service delivery at the respective health facilities.

In collaboration with USAID/ASSIST, the Program conducted VMMC QI baseline assessment at nine

VMMC sites to benchmark quality areas that need to be addressed. The assessment focused on

management systems, supplies, equipment, other VMMC service delivery systems, records

management, infection prevention and waste management. Based on the findings, the facilities were

given support towards improvement. Routine VMMC services assessment using the PEPFAR QI

standard tool guided improvemnet focus for specific health facility challenges. Some health facilities

have had their implementation of VMMC haulted for some time during the year due to quality gaps.

Effort was made by the Program to address and support the facilities through supportive supervison and

mentorship. By the end of the reporting period activities had resumed. Going forward, the Program will

continue to support all VMMC implementing health facilities to ensure that the set standards are

maintained and continous quality improvement interventions are in place focussing on improving the

systems and processes.



In PY4, PHS supported QI & SQIS trainings, post training follow up mentorship and coaching of the

A2F Health as a Business (HaaB2) health

facilities. 78 HaaB2 health facilities were

trained across the coutry reaching 144

participants that included directors

(proprietors), administrators, human resource

managers and techncial health workers. 25

staff of UOMB supervised health facilities

were trained in QI and use of SQIS tool. As a

result of the training, Quality Improvement

action plans were developed for 5 facilities. The trainings aimed at empowering and

strengthening the understanidng and

appreciation of the QI and SQIS approaches

and methods in improving performance and

meeting client health expectations in the

business sense. The trainings made the

participants to relate and appreciate different

dimensions of quality, use of QI tools in gaps

identification, implement and monitor

changes for improvement. During the

reporting period, post training follow up

mentorship and coaching were conducted in

only 44 HaaB2 health facilities during which

practical facility registration were done,

assessment and reporting using the SQIS

online web-based platform and use of the QI approaches and methods to document, monitor and

improve identified implementation gaps through use of documentation journal.

1.2. Strengthened systems for service delivery in private sector facilities

1.2.1. Strengthen skills of health workers

In Quarter 4, the Program conducted trainings for health workers in the private sector aimed at building

their technical skills as follows:

Training and mentorship Format Type and Number of health worker trained in Y4

Representing Number of Facilities

Open Medical Records System Course (Open MRS)

3 day facility based training

18 nurses, clinicians and medical records officers

16 facilities

Open Medical Record System Course

5 day classroom based training

68 M&E officers, data officers, clinicians,

36 facilities

Option B+ (eMTCT) 6 day classroom based training

29 nurses, midwives and clinicians

18 facilities

Comprehensive HIV course 5 weeks online module with 2 day practicum placement

19 midwives, nurses and clinical officers

15 facilities

Long term acting reversible contraceptives

10 day classroom and site based training

245 nurses, midwives, clinical officers and medical officers

46 health facilities

Integrated QI & SQIS Trainings for HaaB2 Health facilities





Permanent methods of family planning (BTL and non-scalpel vasectomy)

10 day classroom and site based training

17 medical officers 16 facilities

Quality Improvement (QI) and self-regulatory quality improvement system (SQIS)


171 facility managers, directors, administration staff, nurses, clinicians,

35 M&E program staff plus research assistants

34 Haab2 facilities

44 facilities

Consolidated guidelines for HIV prevention and treatment in Uganda, 2016

3 day facility based training

1,258 clinical officers, nurses, midwives, medical officers, specialists, laboratory technicians /technologists, pharmacists and support staff


VMMC mentorship 1 day facility based 164 nurses, medical officers, clinical officers and counsellors


Bio risk and Biosafety training 5 day classroom based training

46 laboratory technicians, assistants, technologists and support staff


Bio risk and Biosafety mentorship 2 day facility classroom based

102 laboratory technicians, assistants, technologists and support staff


Laboratory Quality Management Improvement system mentorship

2 day facility based 48 laboratory personnel 20 health facilities

Laboratory Logistics and management

5 day classroom based 20 laboratory technicians, assistants, technologists


HMIS/DHIS II mentorship 1 day facility based 95 records staff, clinicians and nurses


Integrated Management of Malaria including IPTP

1 day facility based 125 nurses, midwives, clinicians, laboratory staff, pharmacy technicians and stores personnel


Mentorship in perinatal audit, HBB+ and HMS, Babies matrix, HMIS 010b (integrated MNCH mentorship)

2 day facility based 145, nurses, midwives, clinicians


TB/HIV co- infection management Course


20 nurses, midwives, clinical officers and medical officers

18 facilities

HMIS/ DHIS II Course 5 day classroom based training

20 clinicians, records staff and M&E staff


VMMC 10 day classroom based and site based training

45 nurses, clinicians, medical officers and counsellors

15 facilities

Nutritional Assessment Counselling and Support (NACS)

5 day classroom based training plus field practicum

34 Clinicians, nurses, midwives medical officers, counsellors

17 facilities





Health Care Waste Management, Injection safety and blood safety

5 day classroom based 35 administrators, clinicians, nurses and in-charges


Malaria in Pregnancy 3 day Classroom based 80, medical officers, nurses, midwives,

45 facilities

Helping Mothers Survive 5 day Classroom based training

59 midwives, clinical officers, medical officers and nurses

40 facilities

Helping Babies Breathe 5 day classroom training

60 Midwives, nurses, clinical officers, anaesthetists, medical officers

40 facilities

HR performance management, record management, QI and medicines management

½ day facility based mentoring training

325 administrators, nurses, clinicians and medical records officers

25 facilities

Human Resource Information Systems (HRIS)

1 day facility based mentoring training

297 administrators, nurses and clinicians

27 facilities

Workload Indicators of Staffing Need (WISN)

1 day facility based mentoring training

39 administrators and clinicians

13 Facilities

Board roles and responsibilities 1 day training workshop for Medical Bureau Board

3 day joint training workshop for Dioceses and facilities

84 Medical Bureau Board members, Diocesan Health Board members and 6 Facility Board members

1 Medical Bureau, 3 Dioceses and 6 Facilities

Finance Management and Internal Controls

2 day training workshop 69 Finance Officers, In-charges and Management Committee members

30 health Facilities

1.2.2. Support targeted continuing medical education (CME)

During site based trainings/mentorships, continuing medical education sessions were used to

disseminate information to health workers in areas of integrated management of malaria, malaria in

pregnancy and safe male circumcision, QI, SQIS, biosafety and biosecurity, laboratory quality

improvement, understanding and utilization of the hub system, laboratory logistics, stock management

and data management/reporting.

1.2.3. Support innovative approaches to task sharing and task shifting

PHS worked with the Infectious Diseases Institute (IDI) to update the online Comprehensive HIV

course to include the new changes in the consolidated 2016 HIV guidelines. This course targets Clinical

Officers, Nurses and Midwives. It aims at building their capacity in providing HIV with minimal

interruption to routine activities at the respective facilities. In Quarter 4, 19 health workers actively

engaged on the online platform and participated in the five-week course in comprehensive HIV services

for clinical officers, nurses and midwives to allow task shifting in places where medical officers are not

available.

1.2.4. Strengthen policies, guidelines, standard operating procedures and job aids

During Quarter 4, PHS obtained soft copies of various policies, guidelines and job aids following a

number of changes in HTS guidelines and HIV treatment guidelines from MOH and other materials

from key stakeholders, had them reproduced and availed to both PFP and PNFP facilities. These

included the following:



a) HTS policy: During the reporting period, PHS liaised with the STD/AIDS Control Program

(ACP) of Ministry of Health and obtained sample copies of the HTS Policy. PHS reproduced

and disseminated these guidelines to all the PHP and PNFP facilities.

b) The Consolidated Care and Treatment Guidelines 2016: These included desk job aides and

manuals that were distributed across 71 program supported facilities.

c) LARC/permamnet methods:PHS also obtained a soft copy from MOH, Engender Health of the

Comprehensive Family Planning Manual, Post Partuum IUD Learners work book, Non- scapel

vasectomy and BTL manuals.These were printed and disseminated to all facilities to guide them

at their respective facility as resource materilas to support continuos professional development.

Other guidelines, policies and job aides printed during Program year 4 included; SQIS and SiMs

manuals, VL guidelines, HBB, ENBC and HMS job aides, pediatric TB algorithm and job aids.

1.2.5. Strengthen health management information systems

1.2.5.1. Identify and support health management information system (HMIS) focal persons

During the quarter, the Program provided onsite mentorship and technical assistance to all 71 supported

sites to ensure complete, good quality and timely submission of HMIS reports. The Program worked

with district biostatisticians and probation officers to ensure timely and accurate entry of data in the

DHIS2 and OVC MIS respectively. Health facility reporting rate in Q4 in the DHIS2 stands at 100%

for monthly reports and 97% for quarterly data. Two health facilities (Qudrah and Munobwa) still have

missing data entry screens in the DHIS2. PHS is following up with the districts and MOH resolve this

challenge. 100% of the OVC sites reported through the MGLSD OVCMIS compared to 96% in Q3.

The two sites that had moved operation to other districts were registered in the new districts and are

now reporting. The Program received and distributed needed HMIS tools to the 71 supported health

facilities. 7 sites were supported through the respective District Health Offices and Joint Medical stores

to receive access to WAOS online reporting and ordering for timely ARV and HIV test kits orders in

addition to the 22 that had received the access earlier.

During the quarter, the Program assigned research assistants to all the 71 health facilities to provide

onsite support in documentation and data management as well as general M&E support. MOUs were

signed between the Health Facility In-charges/Project Coordinators and the Program to last until end of

October 2017. The research assistants carried out brief data needs assessments and developed workplans

aimed at bridging the identified gaps. Among the activities implemented was on-site mentorship of

health workers in using HMIS tools entry of data into UgandaEMR (OpenMRS), data analysis and

utilization. All the sites were also provided with the needed HMIS tools. The 36 (51%) sites supported

in OpenMRS in previous quarters continued with data entry of backlog data while exploring reports

that can be generated by the database. Sites continue to face challenges with huge data backlogs that

may necessitate external support. The Program purchased and provided 11 computers to health

facilitates to support data management specifically in the use UgandaEMR (OpenMRS). Installation of

Open MRS was undertaken in 8 health facilities supervised by the UPMB.

Targeted technical support was provided to 34 OVC sites to improve their data management systems

including updating of their integrated registers, case management files.

1.2.5.2. Strengthen weekly option B+ reporting

The Program continued to work with the AIDS Treatment and Information Centre (ATIC) at IDI to

send weekly SMS reminders to 30 health facilities (4 for Faith based and 26 PFP sites) to submit weekly

option B+ reports. On average, the general reporting rate was 96% from 68% last quarter. Barriers to

reporting have mainly been incorrect report formats, use of unregistered numbers, change in phone

numbers, and change of facility focal persons. However, the improvement in reporting was due to the

continuous weekly reminders and monitoring of the system to ensure complete reporting. The M and E



team also provided regular onsite mentoring and support to ensure that the previously missed reports

were sent through the DHIS2 system.

Figure 11 Option B+ health Facility weekly reporting rates

1.2.6. Strengthen Health Systems in the faith based sector

During Quarter 4, the USAID/Uganda Private Health support program (PHS) implemented the

following Health System Strengthening (HSS) activities:

> Validation and Finalization of the Comprehensive HSS Needs Assessment: A total of 64

stakeholders from the Medical bureaus, Hospitals and Health Centres validated the findings of the

Health System Strengthening Needs Assessment (HSNA) conducted earlier in quarter 3. The report

will be widely disseminated to the stakeholders in first quarter of PY5.

> Integrated HSS facility visits: Integrated teams of technical advisors from Medical Bureaus and

PHS conducted Health systems support visits to health facilities in all regions of Uganda. The

purpose of the visits was to gain deeper understanding of the HSS situation in facilities, and provide

instant support appropriately. Technical advisors of Medical Bureau were supported to make

supporting supervision visits to 25 health facilities. The advisors offered on-spot mentoring to

varying capacity areas including Human resource performance management, finance/asset/medical

records management, QI and medicines management.

1.2.6.1 Improve the availability of human resources to support service delivery in the faith-based

health sector

During the quarter, PHS worked to strengthen the strategic policy frameworks of the 4 Medical bureaus

and health facilities under their respective networks. The task entailed developing Human resource

management manuals for the 4 Bureaus, and model human resource management manuals for Hospitals

and model Charters for Health units. The policies and charters will ensure the existence of codified

approaches for human resource management in Uganda’s faith based health sector/network. The human

resource manuals will be in place within the 1st quarter of PY5. Other human resource activities

implemented include:

Training of Management Committees (MCs) and staff of 27 Health Facilities under UMMB,

UOMB and UPMB in management of the Ministry of Health HRIS. The training included hands

on registration of the facility staff in the HRIS. One of the challenges to the success of the activity

was absence of computer facilities in some Health Units. PHS will work with Medical bureaus to

address gap.

Training of 15 staff and management of 5 health facilities supervised by UOMB in performance

appraisal management. A similar training will be organized for the members of the Health Unit

Management Committees in the first quarter of PY5, to strengthen their ability to supervise staff.

100 100 9785 82

100 100 97 97 97 97 100 100 97

0

50

100

150

Per

cen

tage

rep

ort

ing

rate

Option B+ Reporting rate

2 per. Mov. Avg. (Option B+ Reporting rate)



Workload Indicators of Staffing Need (WISN) human resource management tool was introduced in

13 health facilities under UMMB. The purpose of the activity was to capacitate health facility

managers with the knowledge and skill to systematically make staffing decisions to enable them

utilize their human resources well.

1.2.6.2 Strengthen health leadership and governance in the private sector

1.2.6.2.1. Strengthen health leadership and governance in the private for profit (PFP) sector

Refer to section 1.4.5. Provide business strengthening support

1.2.6.2.2 Strengthen health leadership and governance in the faith-based sector

During the quarter, PHS worked to strengthen the strategic policy frameworks of the 4 Medical bureaus and health facilities under their respective networks. The activity entailed developing Board governance

manuals for the 4 Bureaus, and model Board governance manuals for Hospitals and model Charters for

Hospitals and lower health facilities. The purpose of developing the policies and charters is to ensure

the existence of codified approaches for health governance in Uganda’s faith based health

sector/network. The governance manuals will be ready in the 1st quarter of PY5. Other governance

activities accomplished included:

Review of UOMB draft Strategic Plan 2017 – 2021: The review workshop involved 34 stakeholders

from Health Facilities, Uganda Orthodox Council and UOMB Board and staff. For the past two

years, UOMB only had a draft strategy that focused on requirements for the establishment of the

Bureau. The recognition that the Bureau had had significant transformation beyond the

establishment phase necessitated this activity. UOMB needed to refocus on strategic change in core

purpose areas. Plans are under way to develop a new strategy that will set the direction of the core

purpose components for the existence of the Bureau such as capacity strengthening of the orthodox

medical network, engagement with Government, quality assurance for the Orthodox Medical

Facilities, among others.

Induction and orientation of 11 members of the Board of UMMB in their roles, rights and

responsibilities. Board members were also supported and reviewed the implementation

performance of the Bureau Strategic Plan. Similarly, UCMB was supported to orient 73 Board

members from six different health Facilities and Diocesan Health Boards in their Terms of

Reference and contemporary Health Facility governance issues.

UCMB conducted six Health Assemblies organized by major Hospitals and Dioceses and the

Archdiocese of Kampala bringing together 501 participants representing leaders of Health

Facilities, political leaders, technical public sector officials and community leaders. The assemblies

aimed at promoting transparency, accountability to health care consumers by leaders of health

facilities in the delivery of health care.

1.2.6.3. Improve health financing and finance management in the private sector

During the quarter, PHS worked to strengthen the strategic policy frameworks of the 4 Medical bureaus

and health facilities under their respective networks. The activity entailed developing Finance

management manuals for the 4 Bureaus, and model finance management manuals for Hospitals and

model finance management manuals for health units. The purpose of developing the manuals is to

ensure the existence of codified approaches for finance management in Uganda’s faith based health

sector/network. The finance manuals will be ready in the 1st quarter of PY5. Further, a total of 69

Finance Officers, In-Charges and members of the Management Committees of 30 Health Facilities

under UPMB and UOMB were trained in Finance Management and Internal Controls. The training

aimed to improve skills and knowledge of the participants, required to improve financial management

systems at health facilities.



1.2.6.4. Improve coordination with public facilities and other stakeholders at districts and national

levels

1.2.6.4.1. Strengthen Uganda Healthcare Federation (UHF)

Refer to section 3.3.2. Support UHF to implement strategic plan

1.2.6.4.2. Establish a faith based organization health coordinating mechanism

The draft concept paper for establishing a national faith-based body was shared with medical bureaus

for their input before it is shared with other stakeholders. This sharing will promote buy-in and

ownership of the process by the medical bureaus. The Program will elicit more input from other

stakeholders before a more detailed feasibility study for establishing the faith-based body is instituted.

This phase will be accomplished in the first quarter of PY5.

1.3. Strengthened support for Orphans and Vulnerable Children (OVC)

1.3.1. Support performance based grants to Faith Based and Civil society organizations

The Program provided performance based grants to OVC partners to implement support services

following the Family-Based Approach, PEPFAR/USAID/Uganda Priorities and the Ministry of Gender,

Labor and Social Development (MGLSD) objectives. Key priority activities were delivered through

implementation of a comprehensive OVC support package including: intensifying the 90-90-90

HIV/AIDS Global epidemic control strategy to ensure that OVC are Healthy, Stable, Safe and Schooled.

In the PY October 2016-September 2017, the Program supported 46,572 OVC (31,898 PNFP and

14,674 PFP) from 13,993 households. The Program supported transition of four organizations that

operated in districts of low HIV/AIDS prevalence. These included Kumi Diocese in Kumi District,

Islamic outreach Center in Bukedea District, Lango Diocese in Alebtong District and Kasana Luwero

Diocese in Nakasongola District.

1.3.2: Households Economic strengthening activities

Household Economic empowerment remained key priority intervention and central to the provision of

essential services to OVC Households. This intervention focused on enhancing capacity of OVC and

care giver to increase their incomes and assets growth through:

1.3.2.1. Training of caregivers in business initiation, management and follow up support

This training covered a total of 2,216 new OVC caregivers (535 males and 1,681 females) and equipped

them with skills on identification, initiation and management of income generation projects. Trainers

undertook tracer studies among selected caregivers to ascertain the impact of the previous trainings and

other interventions. Findings from this study revealed significant increase in incomes of caregiver

households and other vulnerable groups that benefited from the previous trainings. However the major

factors constraining growth and development of IGAs include limited access to finance, inadequate

management, technical skills and low economies of scale.

In Masanafu Child and Family Support ( MCAFS) Project and Kakira Out growers Development Fund

(KORD), the Training of Adolescent Girls and Young Women (AGYW) at risk of contracting HIV on

entrepreneurship skills like Soap making, counter book making, Pastries and baking enabled them meet

personal basic needs and reduced their exposure to unstable, exploitative sexual relationships at a tender

age. The training also empowered OVC with life skills that resulted in high self-esteem and

involvement in decision making on issues that affect their lives. A total of one Hundred and Eight (108)

Adolescent girls and young women were trained and equipped with safer health choices and decent

earning opportunities.



1.3.2.2. Training of Village Saving and Loan Association Leaders on Group Dynamics and Money

management skills

A total of 3,250(906 male; 2,344 female) Group leaders from four Hundred and sixty six (466) groups

were equipped with skills to effectively manage group activities. Emphasis during the training was on

group formation and management. More time was spent on the loan disbursement procedure since all

groups are involved in saving and loaning activities. All groups were encouraged to establish loan

management committees. These committees are a prerequisite for successful management of the loan

funds since they are responsible for assessment, disbursement and recovery of the loans advanced to

members.

Follow up on Village Saving and Loan Associations (VSLAs) to offer Technical support and

mentorship in management continued throughout the year. This was jointly done by Social workers,

M&E and Program Accountants. During such follow ups, Groups were educated on basic book

keeping, records management and roles/ responsibilities of leaders. As a sustainability mechanism to

provision of services to OVC, all caregivers are encouraged to join existing groups or form new ones

where they can access loans to start/ grow family enterprises. Many caregivers are successfully running

small scale Businesses from where they are able to raise money to meet basic needs of children under

their care. ECO-AGRIC (through a private company Traidlinks) conducted trainings on market

linkages and opportunities for agricultural products. Through this 68 caregivers were supported to

market their agricultural products of maize and beans to oil companies.

1.3.2.3. Household Vulnerability assessment.

The House hold Vulnerability Assessment was conducted to determine levels of vulnerability of all the

supported caregivers with a view of graduating 70% by September 201?. Results indicated that 41.2%

of the 6,985 households assessed were ready for graduation while over half of the assessed households

were slightly vulnerable. Only 6.9% and 0.1% of the OVC households were found to be moderately and

critically vulnerable respectively. This finding implied that by assessment time, some households could

be graduated while others would be transitioned to incoming Implementing partners.

1.3.3. Support to Apprenticeship and Vocational Training for out of school orphans and vulnerable

children

During the reporting period, the Program procured and distributed start up kits to OVCs that had

completed Vocational/Apprenticeship training in the financial year 2015/2016. A total of 939 OVC

received assorted start up kits in Tailoring, Metal Fabrication, Salon and Hairdressing, shoe making and

repair, Carpentry, building and concrete practice and Baking/ confectioneries. Before the kits are

distributed, the OVC are assessed by the Directorate of Industrial training (D.I.T) to ascertain their

readiness to utilize the skills and startup kits. However trainees of Motor vehicle and cycle mechanics

did not receive their kits. These will be provided in the next quarter.

Teenage Mothers undergoing skills training in Masanafu Child and Family Support in Rubaga Division, Kampala City,

April 2017.



Follow up of OVC who

were previously trained and

were provided with startup

kits was carried to ascertain

the usefulness of the Kits

received and contribution

towards reducing

Household Poverty. This

was done by Field social

workers in various CSOs.

They purposively document

the successes attained by the

OVC graduates. See

example below from

Babirye Norah aged 22

(Chain Foundation -

Sammuka Village)

An additional number of

1,857 (Male 722; Female

1,135) OVC are currently undergoing training in different trades at various training centers and are

expected to complete their training by December 2017 after which they will be assessed and provided

with startup kits.

The Program trained 260 Artisans and Vocational Instructors on the use of Apprenticeship training

manuals. The purpose of this training was to improve the Artisans and Vocational Instructors’

Pedagogical, Testing and Assessment skills. Follow up to ensure that trained instructors are putting in

practice the knowledge and skills acquired reveals that most of the Instructors are now making schemes

Some of the Apprentices who received start up kits at Chain Foundation in Mukono

Some of the OVC visited and were found to be undergoing practical lessons in different CSOs.

“My customers now know my schedule because I go to the garden in the morning and later in the day, I sit on the veranda to work on customers’ clothes. To make a new dress, I charge between 10,000 - 15,000/=. I am able to make at least 5,000 to 15,000 shillings a day. This has really transformed my life as I don’t have to beg anyone for basic necessities. I also contribute to the purchase of other essential needs in the home and pay fees to my 2 siblings. My main Challenge

Norah utilizing her sewing machine given to her as starter up kit by Chain Foundation in

Mukono

however is that some customers delay to pay me and this affects my income streams and planning”



of work and lesson plans before commencement of the training. This has greatly improved the training

and assessment of trainees before graduation and distribution of startup kits.

1.3.4 Support Nutrition and Food Security Interventions

The Program worked with NuDiets Uganda Limited to train Community Volunteers and Village Health

Teams (VHTs) on Nutrition assessment, counselling and food security. One of the key objectives of

training was to build capacity of community systems to link malnourished children to HIV care points

to assess their HIV and TB status. A total of 1,156 (760 Female, 392 Male) Community Volunteers and

VHTS were trained.

Furthermore, the Program trained a total of 3,049 OVC care givers (754 males and 2,259 females) on

food security and Nutrition. The training aimed at equipping caregivers with skills to establish kitchen

gardens, mobilize food locally, enhance their knowledge on appropriate food mix, and identify signs

for malnutrition and referral for further management. The training focused on food grouping, food

handling and preparation, identification, prevention and management of malnutrition at community

level, infant and young child feeding. Food security thematic areas focused on kitchen gardening,

modern farming Techniques, post-harvest handling, value addition, energy saving techniques, referral

and linkages with other actors. The immediate outcomes observed during the training included high

knowledge gained on how to make food mix commonly known as“ ekitoobero” using locally available

materials, establishing kitchen gardens by majority of OVC Care givers across all CSOs, water and

sanitation practices, and identification of malnutrition cases in the community.

1.3.5. Support provision of Formal Education services.

PHS continued to provide Support for the education of the most critically Vulnerable Children

(emphasis on girls). Education support in form of school fees payment and provision of scholastic

materials was made to 12,511 (Male: 5912, Female: 6,599) to ensure they were retained in school. The

Program Social Workers through contact teachers at schools ensured that regular roll calls were made

to check on the attendance and make follow up on those who were missing school.

In order to reduce the cost of providing sanitary towels to adolescent girls, a training on making of re-

usable sanitary towels was organized. A total of 1,080 girls were trained. These will train others in a

cascading way to reach as many vulnerable adolescent girls as possible. The training involved both boys

and girls to reduce stigma and increase affordability and utilization among girls.

School and Home visits were made to offer career guidance and Psycho social support to children.

During Home visits, Social workers distributed scholastic materials to OVC on a case by case basis.

This ensured improved enrollment, retention and completion of school by critically Vulnerable OVC.

Community Volunteers in Mbarara Archdiocese undertaking MUAC Exercise to identify malnourished children.



1.3.6. Support provision of health, water, sanitation and housing

PHS promoted community sensitizations as a strategy to reach young people especially Adolescent

girls and young women with messages on, dangers of early/Teenage Pregnancy, Sexual and

Reproductive Health rights and responsibilities,

Gender Based Violence prevention, life skills

planning and HIV Prevention were carried out by

FBOs/ CSOs. Through these platforms

adolescents were encouraged to get tested for

HIV. A total of 25 Peer groups for both out of

school and in school were formed in Bukedi

Diocese, Family Concepts center and Agape

Nyakibaale to equip young women and

adolescent girls with the much needed life skills

to keep healthy and free of HIV infection. Social

workers continued to sensitise OVC and

caregivers during home visits and VSLA

meetings on good home hygiene standards. OVC

households were encouraged to have all the

hygiene components (e.g Pit latrine, tippy taps

for hand washing facilities and utensils drying

racks). AIDS Orphans Education Trust (AOET) Lira leveraged support from a partner to sink a borehole

was sunk at Boke Parish Adekokwoko Sub-county to increase access to safe water in the area.

1.3.7. Child Protection and Legal Support services

PHS partnered with Ministry of Gender Labour and Social Development (MGLSD) National Trainers

on Child Safeguarding to train OVC grantee staff (The Program Coordinators, Social Workers and

M&E staff) to institutionalize child safeguarding at their organizations level. A total of 88 (Male: 42,

Female 46) OVC grantee staff from 46 CSOs/ FBOs were trained. The immediate outcomes from the

training were development of child safeguarding policies and ensuring respective organizational boards

have them approved. They agreed on the roll out plan to train community volunteers and sign the code

of conduct. All OVC partners identified Focal Persons that will continuously support CSOs on child

safeguarding.

Sensitization on child rights and prevention of child abuse both at home and school were key activities

in the year. Kumi Diocese, International Needs Uganda, Family Spirit Children’s Center, South

Rwenzori Diocese, Caritas Maddo, Family Concepts Center and Bukedi Diocese handled 24 (Male 12,

Female 12)cases of child labor and re-integrated 7 (Male:2, female:5) children with their families. The

Program continued to support births registration and access to birth certificates to children from

critically vulnerable households. A total of 2182 (Male: 1073, Female 1109) OVC were supported to

get birth certificates.

Distribution of scholastic materials was done during Home and school visits.

The Social worker from Kiyinda Mityana Diocese demonstrating how to use tippy tappy to OVC at Mwera R/C in Mityana district.



1.3.8. Psycho Social Support to OVC and their Households

The Program trained 1,271 teachers on provision of psychosocial Support to OVC. The trained teachers

are able to identify danger signs of Psycho-social support distress among OVC, especially those related

to HIV/AIDS, respond appropriately and where necessary engage with caregivers to find solutions. The

Program Social Workers and Community Volunteers including Religious leaders conducted home visits

to OVC households to address any emerging psychosocial issues. Agape Nyakibale, SOS Children’s

Villages, ABC, Bringing Hope to the Family, Family Concepts Center carried out Center Days where

OVC were brought together for recreational and counselling activities at school and community level.

A total of 34,678 OVC (17,534female; males 17,144) were reached with psychosocial services and

basic care services.

1.3.9. Increase access to HIV/AIDS Services

During the Year, PHS continued to focus on children in the pandemic by ensuring that all supported

OVC know their HIV status. A total of 1,257 (Male: 642, Female: 615) HIV positive OVC were

supported to access care and treatment services. During HCT outreach sessions, HIV prevention, STI

screening, information on Sexual and Reproductive Health, Gender Based Violence Prevention were

also provided in Family Concepts Center, Meeting point Kampala, AIDS Orphans Education Trust-Lira

and Bringing Hope to the Family.

1.3.10. Promoting Private Sector Engagement

A total of 15 private companies supported the implementation of OVC activities by providing cash

contributions, market linkages and seedlings for agricultural interventions among others. Below are

some of the examples during the reporting period:

Buikwe Dairy Development Cooperative Society (BDDCS) supported the buying of agriculture

farm inputs during agronomic practice training under International Needs Uganda (INUG) and

facilitated the community reflection meetings.

Kakira Sugar Limited (KSL) has also continued with the child labour awareness campaigns to

discourage child labour practices in the KORD catchment area. In addition, over 6 community

feeder roads have been graded /maintained not only for sugar cane transportation to Kakira Sugar

Factory but also to ensure easy access to other services like market centers for agriculture produce,

education and health services.

The cost share company contributions have also directly led to enrollment and retention of more

OVC in schools (30 OVC supported by DHL and 165 by Kakira Sugar Limited).

1.3.11. Mainstreaming of CBOs OVC activities

The 46 OVC grantees took part in the OVC coordination committees (DOVCCs and SOVCCs)

meetings at the sub-county and district level. The partners also took part in the evaluation of the role of

para-social workers in the implementation of the OVC project led by 4Children project.

1.3.11.1. Supporting children with disabilities:

PHS carried out two surveys in 6 organizations to identify number and challenges faced by OVC with

disabilities. The first survey identified 163 children with physical disability, visual impairment,

deafness, and mental challenges while the second survey identified 178 children with similar

disabilities. PHS innovatively utilized findings to initiate a partnership with National Referral Hospital



Orthopaedic Workshop, National Wheel Chair

Coordination Committee of Ministry of Health

and two local NGOs. A total of 51 out of 341

assessed (14.9%) have since received devices.

CWDs and family members were trained on

device use/repair. Older CWDs accessed

vocational skills training.

1.4. Support business strengthening and increase access to finance

1.4.1. Expand financial outreach through

DCA banks

The Program has continued to work with

Centenary Bank and Ecobank to increase access

to finance for the private health sector. During

year four, the following results were registered.

Centenary Bank continued to register steady growth in its DCA utilization rates. At the end of Quarter

4, utilisation of the USAID/SIDA Health DCA at Centenary Bank reached a cumulative total of UGX

6,362,000,000 (US$ 2,494,902) as illustrated in Figure 1 below. The cumulative utilization rate is 83.2%

of the total UGX 7.65 billion guarantee ceiling, with 116 loans disbursed to 84 borrowers (58 rural, 26

urban). Of these 117 loans, 71 loans (to 57 borrowers) worth UGX 3,782,500,000 (US$1,483,333) have

been fully paid off, and 45 loans (to 27 borrowers) worth UGX 2,554,500,000 (US$1,001,765) remain

outstanding. 14 new loans worth UGX 519,500,000 (US$ 203,726) were disbursed during year 4 to 3

urban borrowers and 11 rural borrowers.

Figure 12. Centenary DCA Utilization as % of Total Guarantee Amount as of 30 September 2017

In Quarter 4, four loans worth UGX 120,000,000 (US$33,333) were booked under the Centenary Bank

DCA. Two of these loans worth UGX 55,000,000 (US$15,278) were used for medical equipment

purchase, and one loan worth UGX 25,000,000 (US$6,944) went to a rural borrower to construct a

maternity wing for the clinic he operates. Most of these loans (3 out of 4) worth went to rural based

borrowers wishing to expand their clinic operations through purchase of medical equipment or

construction of new premises.

Ecobank DCA continues to underperform. The causes of the slow utilization of the Ecobank DCA have

been repeatedly documented over the previous fiscal years. For administrative reasons, USAID has

decided to leave the guarantee in place but asked us not to dedicate further resources to technical

assistance for Ecobank at this time.

At the end of Year 4, Ecobank’s utilization of the DCA had reached a cumulative total of UGX

3,120,000,000 (US$1.22 million) to four borrowers (two rural and two urban), as illustrated in Figure

83.2%

44.8%38.4%

28.8%

54.4%

10.2%

72.9%

30.1%

53.0%55.8%

10.3%5.2%10.2%1.6%

24.6%33.6%

0.8%

21.3%2.8%

Beneficiaries of wheel chairs at Karera Ecumenical Development Organization in Sheema District.



2 below. This is 17.5% utilization

of the total guarantee amount of

UGX 17.85 bn. Of the four loans

placed under coverage, one loan

has been fully paid off. The

current outstanding amount is

UGX 3,057,972,543 for three

borrowers, representing 98% of

the disbursements to date. One

new loan worth US$ 500,000 was

disbursed during year 4 to one

urban borrower to draw a letter of

credit to import pharmaceutical

supplies. A waiver from USAID

was sought for this deal.

The portfolio quality of the DCA

has been mediocre, with one loan

worth UGX 1.25 billion

(US$500,000), composing 95% of

the utilized guarantee amount,

going into default. The bank has

made a claim on the DCA for the

guaranteed portion of that loan.

Figure 13: Ecobank DCA Utilization as a % of Total Guarantee Amount as of 30 September 2017

During a review of Centenary’s guaranteed health loan portfolio in FY 2017, the Program found that

contrary to the requirements of the DCA agreement, Centenary had not requested USAID’s prior written

approval for some loans which may have been used to finance pharmaceuticals. We have now addressed

this anomaly. We identified all the pharmaceuticals and sought a retroactive waiver for them from

USAID. We have now developed the following measures to avoid a repetition of this as follows:

1) We have created a checklist for the bank’s loan personnel to use in verifying qualifying borrowers

and qualifying projects which are eligible for guarantee coverage;

2) We have established a protocol for the banks for requesting prior approval from USAID on loan

requests which include financing for pharmaceuticals;

3) The protocol has been approved by USAID; and

4) The Access to Finance (A2F) Team will provide training to Centenary Bank lending personnel on

how to apply the protocol in FY 2018. It will also be put in place at the new DCA health loan

portfolio guarantee at DFCU Bank.

ALL

Bo

rro

we

rs

Ru

ral

Urb

an

Ne

w a

nd

Fir

st…

Exis

tin

g b

ank…

Fem

ale…

Mal

e o

wn

ed…

Bu

sin

ess

…

Ind

ivid

ual

/ow

…

Clin

ics

Ph

arm

acie

s/…

Med

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…

Equ

ipm

ent…

Den

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s

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Loan

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17.5%

7.0%

10.5%

17.3%

0.2% 0

17.5%17.5%

0.0%0.2%

10.3%

7.0%

0.0%0.0%

7.0%

0.0%0.0%

10.5%

7.0%

0.2%0.0%

10.3%

An example of how this non-DCA financing is making a positive impact is illustrated in the case of Kumi Community Clinic and Imaging Centre. This is a clinic based in Eastern Uganda serving a rural clientele. They participated in our A2F workshop, and we provided TA, linking them to suitable equipment vendors such as Crown Healthcare and Computech. With the support we gave to the clinic, they put together a financing proposal worth UGX 291 million to Centenary Bank for purchasing medical equipment. Kumi Community Clinic and Imaging Centre also made their own contribution worth UGX 80M, making the total cost of medical equipment UGX 371M. The loan was not placed under the Centenary Bank DCA guarantee because the loan repayment period is longer than the remaining life of the guarantee. The non-DCA loan has been used to purchase an X-Ray Machine,X-Ray image reader, printer, computer and ultra sound scan. Kumi Community Clinic Imaging Center's investment in this equipment has directly led to a 62.5% growth in client volume, serving 160 clients per month, along with a 100% annual growth in sales revenue. The clinic has posted an overall monthly net profit of 10,000,000 million UGX. Kumi Community Clinic and Imaging Center's growth includes an increase in the number of its employees from 7 to 16 healthcare professionals who were employed as a direct result of the acquisition of the medical machinery. This includes a radiographer, dark room attendant, a laboratory technician, two enrolled nurses, one nursing assistant and a part time medical officer.



1.4.2. Expand Financial Outreach through Non-DCA Banks

We worked to expand non-DCA financing to the private

health sector in year 4. During the year, we held three

medical equipment A2F workshops in Arua, Lira, and Gulu

for 62 potential borrowers. These workshops also included

two medical equipment vendors and three commercial

banks (Stanbic Bank, DFCU Bank, and Centenary Bank)

interested in equipment financing. Together, the end users,

vendors, and banks could collaborate to establish

partnerships to develop solutions for medical equipment

financing. The A2F team followed up on the leads

generated from these workshops to build an equipment

financing pipeline both for bank and vendor financing.

The Program followed up on the leads generated from

earlier medical equipment financing workshops held in

Mbarara, Mbale and Kampala for 75 potential borrowers to

date. To date we have concluded 10 deals worth US$

$184,571, as summarized in Table 1 below. Of these 10

deals, four were bank-financed, totaling UGX 378,000,000

($108,000), and six were vendor-financed deals worth UGX

268,000,000 ($76,571.43). Rural health care businesses

received UGX 446,000,000 ($127,429), of this financing,

equal to 70% of the total value of the non-DCA lending to date.

Table 1. Non DCA Lending

Non-DCA Financing Investments Supported in Year 4

Non-DCA Investment Amounts in UGX

Non-DCA Investment Amounts in USD (1 USD = UGX 3,500)

10 646,000,000 $184,571

PHS has followed up on the credit pipeline leads generated from the A2F workshops held to date and

has provided technical assistance to a number of healthcare businesses interested in accessing financing

mainly for purposes of medical equipment purchase. Some of the TA included negotiating with vendors

to extend favorable terms and conditions to the 62 potential borrowers that went through our A2F

workshops, for example a reduction in the cash down payment required. In another case, we worked

with Ibanda Comprehensive Medical Centre not only to put together a financing proposal to purchase

equipment from Human Diagnostics Limited, but also for the clinic to offer insurance services through

Jubilee Insurance, in the hope that will increase client coverage for the clinic and contribute to increased

revenue and profitability.

During Quarter 4, the Program followed up on the leads generated from earlier medical equipment

financing workshops held to date. During Quarter 4 we concluded three deals worth US$20,000, as

summarized in Table 2 below. Of these three deals, two were bank-financed, totaling UGX 37,000,000

($10,571), and one was vendor-financed deals worth UGX 33,000,000 ($9,428). Rural health care

businesses received all the UGX 70,000,000 ($127,429) of this financing.

Table 2 : Non DCA financing to the private health sector during Quarter 4 Year 4

Non-DCA Financing Investments Supported in Quarter 1 year 4

Non-DCA Investment Amounts in UGX

Non-DCA Investment Amounts in USD (1 USD = UGX 3,500)

3 UGX 70,000,000 US $20,000

Buy-Back Guarantee: We have learned that the lack of a secondary market for medical equipment

makes our partner banks reluctant to accept such equipment as collateral, creating an obstacle to

equipment financing. We therefore entered into discussions the medical equipment suppliers, Crown

Dr. Opio, radiologist and owner of Kumi Community Clinic and Imaging Centre, shows the X-ray machine which he recently acquired.



Healthcare and Sinoafrica, to see if they would be willing to establish buy-back agreements with banks

to offer assurance that if a borrower defaults on a medical equipment loan and the bank is forced to

repossess that collateral, the bank will be able to resell the equipment and recuperate the loan loss.

Although Sinoafrica has considered buy-back guarantees in the past, they are concerned about

developing a reputation for selling used equipment. Crown Health showed willingness to work with the

PHS Program to provide a buy-back guarantee for medical equipment loans, giving the DCA banks

extra assurance that if a borrower does not repay a loan, the bank could repossess the equipment and

the supplier would buy it back from the bank. Crown is willing to provide a buy-back guarantee under

certain conditions, for example equipment must be returned in reasonable condition and have been fully

serviced by Crown; the value must be above a minimum--i.e. no small items such as blood pressure

cuffs--and the maximum tenor of the buy-back period would be 36 months. The Program has therefore

started working with Crown Healthcare to put in place mechanisms for a ‘buy back’ option for

equipment purchased with financing from the Program’s DCA partner banks. This will be formalized

through a memorandum of understanding to be signed in Quarter 1 of year 5. The Program will also

assist Crown Healthcare to draft partnership proposals for other interested financial institutions.

1.4.3. Provide technical assistance to DCA banks and borrowers (actual and potential)

A corollary to the expansion of financial access of private health care businesses is the need for technical

support. We continued in this TA provider role during the year and provided the following support:

1) Met with Uganda Health Marketing Group (UHMG), whose network of approximately 270 Good

Life clinics is a potential pool of borrowers in our efforts to expand financing for the private health

sector. PHS will provide Access to Finance workshops for the Good Life clinics and provide

training of trainers to UHMG staff to build some in-house capacity for business skills training for

member providers.

2) Invited over 20 Good Life clinics under UHMG network to attend the medical equipment Access

to Finance/Leasing workshops and one of the clinics was able to acquire equipment through vendor

financing.

3) Worked with Soroti Medical Associates Nursing Home, a distressed Centenary Bank DCA

borrower, to restructure their UGX 230 million loan. The program presented the restructuring plan

to the bank, which accepted it.

4) Supported Family Health Clinic in Kiruhura in opening up a bank account with Ecobank Mbarara

Branch to commence an application for a UGX 400M to set up a diagnostic centre.

5) Gave TA support to Family Health Resource Centre to secure vendor financing from Crown

Healthcare to purchase an ultrasound scan worth UGX 60M.

6) Gave TA support to Polycare Clinic in Ntungamo for the purchase of an X-ray machine through

Sino Africa. Sino Africa carried out field visits, provided guidance and made recommendations to

the borrower regarding the structures that will house the X-ray machine by making for them the

architectural plan for the proposed structures.

7) Gave TA support to Lydda Medical Services in their UGX 60 million loan application to DFCU

Bank.

8) Brokered the linkage between Sheema Clinic in Mbarara and Crown Healthcare Care for maternity

equipment worth UGX 15 million.

9) Brokered the linkage between Case Hospital in Kampala and Sino Africa to purchase an ultrasound

scan worth UGX 120 million and a colposcopy worth UGX 30 million.

10) Brokered the linkage between Dr. Omagor Benjamin of Doctor’s Plaza-Soroti and Crown

Healthcare for laboratory equipment worth UGX 4 million.

11) Supported Mbarara Community Hospital to open up a bank account with Ecobank Mbarara Branch

to kick-start a UGX 100M loan application to construct their operating theatre and purchase

laboratory equipment.

12) Brokered the linkage between St. Martin’s Health Centre in Mbale and Crown Healthcare. We also

supported this healthcare business to open up a bank account with Stanbic Bank- Mbale Branch,



and we will assist them with a UGX 200 million loan application for purposes of purchasing medical

equipment.

During Quarter 4, PHS continued to provide technical assistance to a number of HCBs interested in

accessing financing mainly for purposes of medical equipment purchase and also expansion. These are:

> Assisted Ibanda Medical Centre to put together a loan proposal for Centenary Bank for UGX 200M

to complete construction of their clinic and to purchase an X-ray worth UGX 80 million from Sino

Africa.

> Brokered the linkage between Ibanda Comprehensive Medical Centre and Human Diagnostics

Limited a medical equipment vendor for purchase of a CBC machine worth UGX 18M (cash up

front payment); Haematology machine worth UGX 15M with an upfront cash 50% down payment

and the balance with vendor financing to be paid over a period of five months. In addition the HCB

has also been linked to Jubilee insurance and now it’s a service provider for Jubilee Insurance clients

which will help the HCB increase on its clientele and income in the long run.

> Assisted Pikwo Medical Centre in Gulu to put together a loan proposal to Centenary Bank-Gulu

Branch for UGX 17 million to complete construction of their Clinic.

> Assisted Pearl Medical Centre in Lamwo to put together a loan proposal to Centenary Bank-Kitgum

Branch for UGX 20 million to complete construction of their maternity wing.

1.4.4. Supporting USAID in the identification and recommendation of a third health DCA bank

partner

During the year, the Program gave the Washington-based USAID/DCA management office support in

identifying and recommending a third health DCA bank. This support included:

Figure 14: Structure of the DFCU DCA

Making an initial assessment of DFCU Bank’s interest in and strategy for w orking with the private

health sector. The assessment confirmed bank management’s interest in a health DCA guarantee.

Working with DFCU to determine the level of their current health lending portfolio.

Supported the Washington DCA office to carry out a risk assessment/due diligence on DFCU Bank.

The assessment was to determine the suitability of DFCU as a potential partner bank in health lending

with DCA guarantee support from USAID. The efforts have borne fruit, and a new five-year health

DCA agreement has been concluded with DFCU Bank Limited for a US$5 million loan portfolio

guarantee, with a special focus on leasing of medical equipment. USAID will provide an average 50%



guarantee on loans made by DFCU Bank to health care providers, with DFCU Bank having the option

of a variable rate guarantee coverage ranging from as low as 20% to 60% for each individual loan. The

illustration above in Figure 3 summarizes the structure of the guarantee. Under the DCA, USAID/Private

Health Support Program will be the TA provider to the bank to implement a health lending strategy to

maximize utilization. This includes assistance in better understanding the market, loan officer training,

strategy development, and pipeline development support. These skills will assist banks to better

understand the risks associated with lending to the health sector, such as low turnover and possible

delinquency. Developing loan products more tailored for the health sector will also require an improved

understanding by the banking industry of the healthcare market. Other TA offered will include:

1. Assist the bank to determine Development Indicators, Baseline Data and Utilization Targets

2. Monitor both the DCA bank and borrowers

3. Develop pipeline of health deals

4. Provide private health lending data

1.4.5. Provide business strengthening support

During the year, Phase II of the Healthcare as a Business (HaaB II) training and support activities was

launched with Makerere University College of Health Sciences as the business development services

(BDS) provider.

Working together with the BDS provider, training packages—including participant’s manual,

facilitator’s manual, power point slides, pre-test, post-test, and test key—for six modules essential for

managing growing health care businesses or large hospitals were developed and approved by the PHS

program. These modules are: Inventory Management in Your Health Care Business; Risk Management

for Your Health Care Business; Internal Controls and Audit for Your Health Care Business; Financial

Analysis for Your Health Care Business; Corporate Governance for Your Health Care Business; and

Succession Planning for Your Health Care Business.

Makerere College of Health Sciences commenced the training of managers and owners of small and

medium healthcare businesses and large Kampala hospitals, and all HaaB II workshops were delivered

as planned. Four individual business counselling visits were held during the year.

HaaB II post-training monitoring visits to the HaaB II beneficiary health care businesses sites were

made as part of the programs role of providing supervisory and oversight guidance to the project. The

feedback was very positive: HCBs found the training and business counselling very useful, as it

demystified financial information and provided skills to interpret financial statements, control

inventory, calculate and interpret financial ratios, and developed the ability to carry out trends analysis

and to make decisions based on financial statements,. The ability to make decisions using financial

statements has encouraged the smaller HCBs to be more diligent in keeping records that can enable the

preparation of financial statements.

During the year working with the program quality team and the Uganda Health Federation’s quality and

accreditation team, the SQIS and the QI training began for the HaaB II beneficiary health care

businesses.

The Program also held inception meetings with the bureaus, associations and franchise networks as part

of the strategy for ensuring that the HaaB training continues to reach a wider pool of health care

businesses even after the project closes. These meetings included Uganda Protestant Medical Bureau

(UPMB), Program for Accessible health, Communication and Education (PACE, Catholic Medical

Bureau, Uganda Private Midwives’ Association and Uganda Health Federation.

During Year 4, Quarter 4, the following achievements were made:

˃ The third and fourth business counselling sessions were held. During the third business counselling

visit, 68 small-medium health care businesses (HCBs) and 10 large hospitals were mentored with a

focus on reviewing and/or developing written internal controls, beginning trend analysis, reviewing



the status of the stock cards and remedial counseling on financial record keeping and financial

reporting. For the larger HCBs, the third visit was focused on trend and common size ratio analysis

and succession planning activities. During the fourth counselling visit, 70 small-medium health care

businesses (HCBs) and 10 large hospitals were mentored. For the small and medium HCBs, the

focus was to develop a business improvement plan, inventory control and continued review on

updating the stock cards, more trend analysis of their financial information, and colleting monthly

HMIS reports. For the large Kampala hospitals, the fourth visit was focused on developing business

improvement plans.

˃ The on-site training workshops in SQIS and QI mentoring took place during the quarter for the

HaaB II beneficiary health care businesses in the Northern, Western and part of the Eastern regions.

The health care businesses have put into place quality teams and there is visible quality

improvement even at the larger health care businesses.

˃ As part of sustainability for the HaaB activities, discussions on integrating the HaaB modules into

Makerere’s medical school curriculum began and culminated into Makerere sending a briefer

outlining the process of getting this idea off the ground and the resource implications for follow up.

Follow up meetings were held with the Head of Social Franchise, Marie Stopes Uganda, the

Executing Director of Uganda Health Federation and with the Uganda Private Midwives

Association to begin the process of institutionalizing HaaB.

˃ In our role of providing supervisory and oversight guidance to the project, HaaB II post training

monitoring visits and interviews were held with the smaller and larger health care businesses in

Kampala and Wakiso. Successes with the HaaB training continue to be registered at the health

care businesses with many health care businesses developing and implementing internal controls,

calculating financial ratios and interpreting them, updating stock cards and controlling inventory.

Some of the health care businesses have put into place quality teams and there is visible

improvement even with the larger health care businesses.

˃ As part of supporting the health care businesses in creating business linkages, the HaaB II health

care businesses were invited to participate at the Uganda Health Federation Business Event 2017

which brought together health sector players to network, share knowledge and gain experience.

1.5. Program Transition plan Implementation

During the reporting period, PHS held transition

meetings with health facilities and incoming

implementing partners (IP’s) during which the

IP’s that were expected to support the different

regions were introduced to the facilities. These

were attended by the facility staffs,

representatives of incoming IP’s, and Program

staff. Meetings have been held with IPs that

include IDI, Makerere University Walter Reed

Program and Rakai Health Sciences Program.

During these meetings, PHS discussed facility

implementation models and support, work plans,

implementation budgets for PNFP sites and asset

registers. Th e Program continued supporting all

health facilities for sustained reporting as well as

un-interrupted supply of medicines, other

supplies to avoid disruption in service delivery

and conclude planned capacity building efforts.

The Program hired a Transitions Manager to lead this process. Going forward, the Program will

continue to hold stakeholder meetings, engage the incoming IPs and health facilities to enable a

seamless transition process.

Transition meeting held at Hotel Africana. In attendance are PHS Program staff, IDI representatives, Mildmay Uganda and representatives from partner facilities from Kampala District, Wakiso District and Bunyoro region.



Intermediate Result (IR) 2. Increased affordability of private health services and products

2.1. Reducing the prices of health products and services

2.1.1. Provide access to income generating opportunities for HIV/AIDS peer support groups

During the fourth quarter, the Program continued to provide access to income generating opportunities

through its performance based grant with Child Health Education and Development Foundation

(CEDO), a civil society organization. The grant promotes skills and livelihood trainings, enterprise

development, and income growth activities amongst OVC VSLA groups and HIV/AIDS peer support

groups in Wakiso, Jinja, Sheema and Rukungiri. During the first six months of the grant, the Program

conducted the following activities:

Adaption of existing training guides to tailor them for starting and improving their businesses

Selection of groups and strengthening their capacity in managing and sustaining a group enterprise

Strengthening the skills of project participants through tailor made business improvement training

sessions

Orientation of vocational institutions and local artisans on the delivery of required apprenticeship

and vocational skills

Facilitating placement of project beneficiaries to vocational centers/local artisans for non-formal

skills development to enable them to start their own enterprises

Placement of older beneficiaries 25+ years from urban centers in modern small-scale farming

Mobilization of project beneficiaries to appreciate community based health insurance

Carrying out home visits to individual member households (25 per District) to track behavioral

changes in the practice of good financial management and other recommended practices

Convening monthly progress review and coordination meetings to share notes, review progress

against set targets, and agree on actions that could ensure quality project implementation.

Table 3: Modules and number of beneficiaries trained per module

Training modules Beneficiaries Against annual target

Start and Improve your business 3,183 (53% of the overall annual target).

Participants placed for urban farming trainings 1,072 (53.6% of the annual target)

Linked to vocational centers/local artisans for non-formal skills development to enable them start own enterprises

614 (30.7% of annual target)

During Year 4, the Program developed a scope of work for a performance based grant agreement to

increase the ability of HIV/AIDS peer support groups members, VSLA group members, and their

households in Program target districts to pay for health services via various economic strengthening

initiatives. Through a competitive procurement process, the Program selected Child Rights

Empowerment and Development Organization (CEDO), to support this activity. The grantee conducted

the following initial activities in the four target districts of Jinja, Rukungiri, Sheema and Wakiso: 1)

Identified targeted beneficiaries and conducted a baseline assessment for the targeted

households/groups, 2) Conducted mapping to establish the available vocational institutions and local

artisans to offer apprenticeship training opportunities to the beneficiaries, and 3) Conducted a household

livelihoods and market assessment/survey.

2,046 out of a targeted 2,400 beneficiaries were identified and baseline information obtained to inform

benchmarks for subsequent engagements. The reason for reaching out to less than the targeted number



was that the survey teams had to go to the

respective district authorities for introductory

letters during a time when the responsible

officers/authorities were participating in

workshops to develop district budgets for FY

2017. This slowed down progress of the activity.

However, four district-based-mapping exercises

were undertaken to ascertain availability of

vocational and apprenticeship opportunities and

their capacities. To facilitate placement and

apprenticeship opportunities in small and micro-

scale industries, 40 partners (including NGOs,

vocational centers and artisans) were identified

to do so in each of the three mapped districts. An

average of 10 institutions per district was

selected after the capacity assessment for each institution. A database which profiles the baseline

information for the targeted beneficiaries was put in place. 1,367 of the direct project beneficiaries (57%

of the target) were oriented on the market-driven vocational and livelihoods skills they would wish to

take based on the market survey findings. Below is a table summarizing key opportunities identified

during the district based mapping.

Table 4: Key opportunities identified within each district

SHEEMA RUKUNGIRI JINJA WAKISO

› Banana bulking with emphasis on formation of collection centers and business links with large markets ( especially Kampala)

› Growing urbanization with need for support services especially in places with lower supplies of foods such as vegetables

› A linear network of roads with connectivity to the town and markets.

› Rice growing and trading especially in Bwambara subcounty

› Matoke growing and trading in Bunganga and Nyakishenyi sub-counties

› Irish, maize, beans and ground nuts growing especially in Nyakishenyi

› Support services such as saloons & catering services

› Value addition and bi product use on milk ghee making, ice cream among others

› A strong factory base thus available employment and business potential for skilled beneficiaries

› Contemporary farming in areas like rabbits rearing, poultry among others

› The district is intertwined with a strong road network connecting it to the wider Nansana, Matugga, Kawempe and Kampala market

› Urban farming including vegetable growing, rabbits rearing, poultry among others

› Trade and commerce

2.1.2. Facilitate dialogue between MOH and private health sector to rationalize financing for

health

During Year 4, the Program worked with the Uganda Healthcare Federation (UHF) to get health

financing on the MOH’s agenda. The Program approached the Ministry of Health, particularly the

Planning Department, and identified which tasks from the National Health Financing Strategy agenda

were most appropriate to engage MOH with. The purpose was to assist UHF ensure that the private

sector is included in MOH’s upcoming Performance Based Financing initiatives since the PNFP’s had

been included while the private healthcare providers (PHP’s) had not. After a series of consultative

meetings between UHF and the MOH, UHF was able to get MOH to have PHP’s participate in its World

Bank supported results based financing initiatives such as the vouchers for pregnant mothers.

CEDO team during the capacity assessment visit to the artisan to offer training in modern small-scale farming.



2.1.3. Supporting the passage of the health financing strategy and national health insurance bill

During the fourth quarter, the Program worked with UHF to review the Management Sciences for

Health (MSH) terms of reference on costing the national health insurance. The Program supported UHF

to review the MSH terms of reference on costing the national health insurance package of services. The

Program found that policy considerations had not been made in the TOR’s and worked with MSH to

include policy advocacy on best practices from other successful African health insurance programs.

During Year 4, the Program provided actuarial consultancy services to select private health insurance

providers and health management organizations (HMO’s) in Uganda to enable them to enroll more

members and develop a health insurance product that they can market to individuals and integrate with

the proposed national health insurance scheme (NHIS) once various MOH initiatives on costing are

concluded. For each participating company that provided sufficient information, individual actuarial

reports were provided. These reports included an overall business overview; relevant trends in

experience and profitability, claims reserving; premium and pricing adequacy; adequacy of reinsurance

arrangements; asset and liability management; and solvency and capital requirements for each.

The Program further developed an action plan for the private health insurance industry (including the

HMO’s), to engage with the MOH as the proposed National Health Insurance Scheme is implemented.

A major finding of this study was that a minimum benefit package for an average Ugandan who can

afford private health insurance is as summarized in Table 5 below:

Table 5: Health Insurance Benefit Package (Annual limits)

Benefit Package A. Limit for a shared family benefit B. Limit for an individual benefit

Outpatient excluding Dental and Optical

UGX 1.5M per family (USD 420) UGX 500,000 per person (USD 140)

Outpatient Co-pay amount per visit

UGX 5,000 (USD 2) UGX 5,000 (USD 2)

Inpatient Cover with standard exclusions

UGX 5M per family

(USD 1,400)

UGX 3M per person (USD 835)

Chronic Limit within Inpatient 40% 40%

Maternity Limit within inpatient UGX 1M per family (USD 280) UGX 1M (USD 280)

The recommended pricing based on statistics provided by the participants of this study was as follows.

The pricing was based on the type of private health facility that would be providing the package, i.e.

whether it was an insurance company or an HMO which owns its own hospital facilities, and on whether

it was an individual or shared benefits/family plan being purchased.

Table 6: Proposed Pricing for the individual benefit package (Annual premiums)

Proposed Pricing for the individual benefit package

Private Health Insurers (UGX)

Health Management Organizations (UGX)

Private Health Insurers (USD)

Health Management Organizations (USD)

Outpatient Premium 105,762 114,107 30 32

Inpatient Premium 47,256 45,944 13 13

Maternity Premium 487,482 422,964 135 117

Total Premium 640,500 583,015 $179 $162



Table 7: Proposed Pricing for the shared benefit package – Annual premium for each additional member

Proposed Pricing for the shared benefit package – Premium for each additional member

Private Health Insurers (UGX)

Health Management Organizations (UGX)

Private Health Insurers (USD)

Health Management Organizations (USD)

Member (M) 755,875 694,384 208 191

M+1 753,473 692,128 207 190

M+2 491,711 446,314 135 123

M+3 491,711 446,314 135 123

M+4 466,667 422,796 128 116

M+5 466,667 422,796 128 116

M+6 466,667 422,796 128 116

The proposed premium is expected to increase by 15% to allow for medical inflation each year. At a

minimum, the premium increase will be tagged to the country’s Consumer Price Index (CPI). The

proposal was shared through a presentation to a Ministry of Health representative. The MOH is open to

collaboration with the private insurance industry to meet the objectives of universal health care coverage

and the proposed National Health Insurance Bill. MOH advised that a joint dissemination session

between the private insurers and the ministry would be a key step in charting a collaborative way

forward since the MOH is also in the process of defining its benefit plan and package via a team of

medical consultants. The Program will schedule these sessions during Year 5.

2.1.4. Exploring the possibility of a drug benefit plan as an interim step for national health

insurance

During the fourth quarter, the Program started estimating the cost of providing a drug benefit plan (DBP)

under the proposed national health insurance scheme. The Program developed a scope of work for how

to develop the DBP that included the following activities.

Undertaking a market survey to determine average retail and wholesale prices prevailing to

determine prices for the different elements (drugs or medicines) in the DBP package.

Determining a reimbursement price by a) adding an agreed dispensing mark-up to the average

wholesale price already determined, or b) negotiating and agreeing with pharmacies on the

reimbursement prices, without necessarily going into costs and dispensing fees or mark-ups.

Quantifying the drug package to manage service cases and utilization levels annually.

Estimating the total cost of the drug package. The total annual cost for the NHIS package (or the

agreed DBP) will then be estimated after by using a feasible average price determined.

During Year 4, the Program developed a concept note to guide the drug benefit plan development

process. The Program developed a scope of work and solicited for proposals to enable it to conduct this

costing study to answer critical questions regarding developing a drug benefit plan (DBP). The purpose

of the plan is to address challenges, particularly for the poor, to enable them to obtain prescribed drugs

and medicines with the proposed benefit package to be rolled into an eventual National Health Insurance

Scheme (NHIS) in Uganda. When the plan is completed, it will outline a basket of essential drugs and

health products through qualified, quality private drug shops that Ugandans, covered under the NHIS

scheme, can acquire at no extra cost.



2.2. Increasing Health Services and Medicines Pricing Transparency

2.2.1. Conduct a pharmacy and drug shop census in Kampala to augment ongoing KCCA facility

census

During the fourth quarter, the Program shared the Kampala City Council Authority (KCCA) census

findings with the NDA to chart a way forward on how best to address inequities in access to medicines

and compliance with regulations within Kampala. NDA and KCCA will use the census data and GIS

maps to better understand the number of pharmacies/drug shops/stores, types of pharmacies and drug

shops (wholesale, retailer), geographic location of pharmacies and drug shops, hours of operation, and

a range of other services (e.g. distribution), staffing configuration, and licensure compliance.

During Year 4, the Program laid the ground work to conduct a pharmacy census in the Kampala Capital

City Authority (KCCA) region. The Program met with the National Drug Authority (NDA) and the

KCCA to determine the scope for the pharmacy and drug shop census. The census covered the five

divisions of Kampala City, including: Kampala Central, Nakawa, Makindye, Lubaga and Kawempe.

Targeted pharmacies for this census included public pharmacies (key public pharmacies found in

public/government hospitals), private pharmacies, and drug shops.

Figure 15: GIS map for the northern part of Nakawa sub-division, Kampala

Below are key findings from the KCCA census:

The number of both pharmacies and drugs shops expanded dramatically in the last six years.

However, this growth in retail pharmacies and drugs shops has not been planned nor strategic.

Private pharmacies are concentrated in Kampala Central (39%) – mostly around the few major

hospitals. Drug shops make up for the lack of pharmacies in these divisions: one can find a drug

shop in all five divisions, with a higher concentration in Lubaga. The uneven distribution of

pharmacies creates problems in access.

The rapid growth in pharma retail outlets has not necessarily resulted in increased capacity in the

pharma sector. Most pharmacies are small to medium size, stand-alone businesses that employ less

than 5 staff persons. Moreover, the majority (41%) see on average 25 to 50 clients daily, implying

they potentially have excess capacity.



The rapid growth is a missed opportunity to increase access to key public health services through

private pharmacies and drugs shops. The data showed that more than half (53%) the drug shops

offer family planning methods, probably because the majority of drug shop owners are retired MOH

nurses trained in FP counselling. But a very small percentage offered basic health services.

Compliance with regulations among private pharmacies and drug shops is uneven. Although, a

relatively large number of pharmacies and drug shops are registered (83% and 97%, respectively),

most facility licenses are not valid and were expired. Possible explanations for the alarming number

of invalid facility licenses include: i) few facilities being aware of recent changes in NDA

regulations, and ii) many facilities waiting to register in the new year to avoid paying full licensing

fees for a partial year. Moreover, drugs shops dispensed drugs that were not part of their scope.

In addition to the non-compliance issues, the several gaps in the systems supporting pharmacies

and drug shops. The facility census highlights the acute shortage in human resource in the pharma

sector. Of the facilities contacted, only 46% had a full-time pharmacist while 24% had a pharmacy

technician/ dispenser. Most facilities rely on health cadres – clinical officer, registered nurse or

midwife – who are not trained in good prescribing practices to dispense medicines.

2.2.2. Conduct an Awareness Campaign on Rational Use of Medicines and Disseminate

recommended EMHSL Commodity Prices

During the fourth quarter, the Program concluded its nine-month campaign on promoting the rational

use of medicines and disseminating recommended retail prices for essential medicines. The Program

assessed the success of the campaign throughout retail medicine outlets in Mukono, Jinja, and Kamuli

districts. Key results of its assessment showed that in all three districts, the proportion of respondents

who reported that private drug providers clearly provide information on use of medicines increased

slightly, from 71% to 73%. Mukono and Jinja registered marked increases, from 62% to 93% and from

56% to 71%, respectively. The proportion of respondents who agree that medicines envelops are clearly

marked with the name of medicine, dose and duration of treatment increased slightly, from 60% to 66%

on average. The largest increase was registered in Mukono,

from 55% to 86%.

The proportion of respondents who report that private health

providers consider their ability to pay when they decide which

medicines to sell increased markedly from 21% to 37%.

Likewise, the proportion that reported that medicines costs in

private drug outlets in their area are affordable increased

marginally from 18% to 20%, on average. The highest

proportion was registered in Jinja, at 37%, from 25%.

However, the proportion of respondents who report that the

quality of services delivered by private health care providers

in their neighborhood is good increased significantly, from

46% to 65%, overall. Mukono district registered the biggest

increase, from just 34% in the baseline survey, to 97% in the

end line survey. The results further show that the community

practices in seeking quality services improved. For instance,

the proportion of the respondents who reported that they only

went to a licensed health facility such as an RMO to get their

medicines more than doubled, from 33% to 72%.

During Year 4, the Program achieved a reduction in essential

medicines sold by RMOs in particular areas. The Program

monitored trends in medicine prices in the three target districts to track price trends. An assessment

conducted in July in Jinja district revealed that 15 PHPs were selling ACTs between UGX 3500 - 4500

and only four facilities namely, Mwinike drug shop in Buwenge town council, Calvary drug shop in

Wanyange subcounty, and Nabweteme drug shop and Erunasser drug shop in Mafubira sub-county

were selling ACTs in the range of UGX 5000 - 6000. The tracking of medicine prices enabled the

HEPS staff member Mr. J.B. Luyima and Mr. Julius Mayengo of the NDA during a radio talk show on Radio Simba



Program to engage the district drug inspector (DDI) Jinja on the issue of Mafubira having higher-than-

average prices for medicines. He noted it was because they were facing high licensing charges from the

town council.

The Program therefore engaged members of RMO associations and the subcounty local governments

over the issue of high trading license fees. The DDI and private health sector association members

proceeded to engage subcounty leaders in Kisozi, Balawoli and Nawanyago on the problem of high

licensing fees which were being transferred to health consumers through higher medicine prices. In

these specific sub-counties, it has been agreed that PHPs will be assessed according to the value of the

businesses effective 2017/18 financial year.

2.2.3. Support pooled procurement for private health providers

During the fourth quarter, the Program worked with Joint Medical Stores (JMS) to provide pooled

procurement services to four private health sector associations and one district based private health

sector association. The Program provided legal, coordination and logistical support services to the

Uganda Healthcare Federation (UHF), Uganda Private Midwives Association (UPMA), Uganda Private

Health Training Institution Association (UPHTIA), Uganda Community Based Health Care Association

(UBHCA), and Mukono District Private Health Sector Association. Specific activities provided

included training in pooled procurement methods, and legal reviews of the associations’ registrations

so they can engage in pooled procurement services. This work is ongoing and will continue into

Program Year 5.

During Year 4, the Program provided legal, coordination and logistical services to private health sector

associations. Specific activities the Program conducted for the private health sector associations

included 1) Reviewing and improving existing legal documents, 2) Assisting private sector associations

to register appropriately so they can engage in pooled procurement activities, and 3) Training

association members on pooled procurement, member recruitment and ordering guidelines.

2.2.4. Disseminating the professional fee guidelines

During the fourth quarter, as agreed during prior engagements with the Uganda Medical Association,

the Program scheduled eight professional fee guidelines dissemination meetings with the Uganda

Medical Association members in the four geographical regions of Uganda (Eastern, Western, Northern

and Central regions). During these

meetings, the Program will

facilitate adoption of the guidelines

within the private health sector by

sharing them with the respective

district based regulatory

institutions, holding consultative

meetings with all the medical

professional associations’

representatives in the districts, and

undertaking the necessary

consultative meetings with the

Uganda Medical and Dental

Practitioners Council to gazette the

fees.

During Year 4, the Program

finalized its work with the Uganda

Medical Association (UMA) and

the Uganda Medical and Dental

Practitioners Council (UMDPC) to develop professional fee guidelines for the private health sector. The

Program held planning meetings with the Uganda Medical Association (UMA), the Uganda Dental

“Medical Council Sets Doctors’ Fees” article in the Daily Monitor. January 9, 2017



Association (UDA), and the Uganda Private Medical Practitioners Association (UPMPA) to develop a

way forward on how to disseminate the final guidelines. The stakeholders agreed that a bigger meeting

be held with all UMA, UDA, and UPMPA individual members to solicit their input and

recommendations on how best to disseminate the guidelines. UMA had raised concerns that some of its

members were opposed to the dissemination of the professional fee guidelines because of

misinformation that the fees had already been gazetted by the regulatory councils. As a result, the

Program organized a consultative meeting with all stakeholders at which UMA members unanimously

agreed to conduct stakeholder consultations to review the updated guidelines before proceeding with

the regional disseminations. These disseminations will continue into Year 5.

2.3. Limiting financial barriers to accessing health services

2.3.1. Promote use of information and communication technology (ICT) in health

During the quarter, the Program signed MOU’s with six high volume sites to take on e-health students

from institutions with information and communication technologies (ICT) programs. However, the ICT

institution with which the Program signed an MOU, International Health Sciences University (IHSU),

did not have any graduate students ready for placement by the end of the reporting period. According

to IHSU, the first batch of graduating students will be ready for placement in January 2018.

During Year 4, facilitated the process of working towards improving the quality of health data and

information services in five private health facilities by signing an MOU with IHSU. The purpose of the

MOU was to develop e-health solutions, support data systems management processes, and provide

recommendations on how developed solutions could be adopted, scaled up, and institutionalized by

Program health facilities. The Program therefore identified six high volume facilities to benefit from

this initiative. The facilities were Family Health Resource Centre in Kiruhura district, Engari

Community Health Centre in Kiruhura district, Mayanja Memorial Hospital in Mbarara district, Ishaka

Adventist Hospital in Ishaka district, St. Francis Buluba Hospital in Mayuge district, and Meeting Point

Kampala in Kampala district.

2.3.2. Promoting health insurance and health savings with VSLA groups

During the fourth quarter, the Program worked with Integrated Community Based Initiatives (ICOBI)

through a performance based grant to promote and provide community health insurance (CHI) to 1,350

households (with up to 7,227 beneficiaries) in the rural and peri urban communities of Sheema,

Rukungiri, Jinja and Wakiso districts. During the quarter the Program specifically:

42 additional community health volunteers were identified in the four target districts to boost

mobilization of groups and households to be enrolled in the project.

Five additional health facilities were mapped and assessed.

Financial Savings groups’ leaders were mobilized and trained on saving for health concepts as well

as accessing health care under a health Plan.

Over 600 district and sub county leaders were mobilized and sensitized on the community health

insurance.

During Year 4, the first enrolment of clients on community health insurance was initiated in the four

target districts of Sheema, Rukungiri, Jinja, and Wakiso. Identity cards were distributed to all the

enrolled members. Five MOU’s were signed with five different private health providers after

negotiations and sensitizations on how community health insurance is conducted. By the end of the first

12-month phase of the performance based grant, a total of UGX 35.8 million shillings had been

collected for health savings amongst the five private health facilities.



2.3.3. Document maternal health voucher program in Kiruhura district to demonstrate success of

privately financed self-sustaining voucher to delivery critical health services

During the fourth quarter, the Program completed the process of documenting the maternal health

voucher program at Family Health Resource Center, Kiruhura. The Program found the following

structure on the FHRC model:

The voucher cards with health services were designed, printed, marketed and purchased by women

who in turn used them to access health services from the FHRC or from the two outreach posts of

Rwetamu and Biguri.

The voucher card entitled the holder the four visits of antenatal care, STI screening, delivery,

postnatal care and Family Planning, specific tests such as; hemoglobin , TB, HIV and syphilis

screening. For other persons who were screened for STIs and other infections, treatment costs would

be subsidized so they would end up paying 60% of the cost.

Most respondents learnt about the FHRC voucher scheme through the FHRC health workers while

the smallest category learnt about it through VHTs who were by design supposed to sell and inform

the masses about the voucher scheme.

The Program found that the FHRC voucher scheme contributed immensely to the improvement of

health seeking behaviors among the women of Kiruhura district. Below are the RH/FP related outcomes

realized under the FHRC voucher scheme for mothers. The program came up with the following

recommendations for scaling up a similar approach:

There is need to link the innovative voucher scheme to the strategic health financing plan in the

country to increase its strategic importance.

Beneficiary awareness is crucial for the voucher system to succeed. The voucher benefits should be

made universally known to all voucher clients. Increasing awareness of program benefits among

target populations is thus necessary for demand creation. Awareness among women on subsidized

services and financial benefits covered by voucher requires expanding demand creation channels at

the community level.

There is need to link the marketing power of the other voucher schemes provided in the private

sector using social franchise umbrella CSOs. Because the funding is low especially for startup,

continuation will require working in combination with a social franchise which are becoming much

more interested in the voucher approach.

The treatment or referral emergency transport for the services purchased by the voucher need to be

offered.

VHTs’ roles of distribution and marketing the voucher has to be accentuated where there are

intentions of scaling up because the current assessment revealed that they fell short in the

highlighted areas.

Documentation of processes and activities at the facilities is crucial so monitoring and eventual

impact measurement can be made easy and smooth.

The voucher scheme could target populations with preferences for private sector providers.

The voucher scheme could target private health facilities.

Create space for claims processing and fraud control and let different entities manage the different

processes: not all by the same manager.

Setting up a voucher scheme monitoring system to facilitate documentation, claims processing, and

fraud control is essential. r



2.4. Promoting preventative care amongst workplace based clients and health providers

2.4.1. Health talks amongst private health insurers’ and health management organizations’

membership to encourage health seeking behaviour

During the fourth quarter, the Program reprinted over 100 HTS guidelines and policies and 210 family

planning manuals and disseminated the MOH health information material on nutrition, prevention of

malaria in pregnancy, and tuberculosis prevention amongst its 71 Program sites.

During Year 4, the Program confirmed UHF and two large health management organizations (African

Air Rescue (AAR) and International Air Ambulance (IAA’s) willingness to provide preventative care

services to their members. The Program identified health management organizations to provide health

talks to encourage health seeking behavior. UHF introduced the Program to AAR Health Services

Limited, one of two large health management organizations, to participate in this activity. The purpose

of the partnership with AAR was to engage it to provide health promotion services to their insured

members with a focus on identifying key populations, such as men, for HTS services and linking them

to care. However due to the rationalization process and scaling down of Program sites, the Program did

not further pursue this activity with AAR.

2.4.2. Updating and Enforcing National referral guidelines

During the fourth quarter, the Program initiated the process of reviewing and updating the national

referral guidelines and providing recommendations to MOH on how they can be institutionalized. The

study, conducted by Quality Health International Consultants (QHIC), has so far found that the

haphazard way referrals currently exist in the country has resulted in inefficiencies in the health system

such as overcrowding of tertiary health facilities where the public perceives the personnel, equipment

and investigative capacity to be of superior quality. The guidelines outlined a new referral chain and

flow as detailed in the figure 8 below.

Figure 16: Proposed National Referral Chain and Flow

Proposed Uganda National Health Referral Chain

The diagram shows a more streamlined flow of referred patients from VHTs to higher level facilities

and between facilities of the same level. The flow considers both public and private health facilities.



The referral chain also depicts a pyramid-like structure of the facilities denoting the existence of far

more abundant lower level primary health care (PHC) facilities than tertiary level hospitals and a

corresponding expectation that fewer patients and clients should be seeking care at tertiary facilities

where there are fewer but higher trained personnel. With the expected implementation of the National

Health Insurance Scheme soon, the PHC facilities will be made gatekeeper facilities for the scheme.



Intermediate Result (IR) 3. Improved quality of private health sector facilities and services

3.1. Implement SQIS and other continuous quality improvement mechanisms

3.1.1. Roll out of the self-regulatory quality improvement system (SQIS)

During the fourth quarter, the Program enrolled up to 41 health facilities on the online SQIS from over

20 districts. Wakiso district had the highest number of facilities (38).

During Year 4, a total of 335 facilities were enrolled onto the SQIS platform. Out of these, 219 facilities

were supported to self-assess on the online SQIS platform in 33 districts. Health facilities can now

monitor their quality improvement progress through comparing and analyzing the different series of

assessments they submit in the system. Health workers will also be able to prepare better for pre-

licensing inspections. Also, during the year, the Program, in partnership with the Intrahealth Capacity

Project, printed and disseminated over 2,000 SQIS tool kits. Health facilities can now access a tool kit

from the councils at the time of registration. This will enable facilities to understand the requirements

at registration.

3.1.2. Link the Health as a Business (HaaB) network facilities to SQIS

During the fourth quarter, the Program supported five-day integrated Quality Improvement (QI) and

SQIS trainings, follow up mentorships, and coaching of the

Program facilities engaged in the access to finance initiatives.

During Year 4, 78 HaaB-participating health facilities were

trained across the country reaching 144 participants. These

included facility directors (proprietors), administrators,

human resource managers and technical health workers. The

trainings aimed at providing the skills and knowledge to effect

appreciation of quality improvement approaches and

application of the SQIS tool to assess and improve health

service delivery in the private health sector. The trainings also

aimed at empowering and strengthening an understanding and

appreciation of the QI and SQIS approaches and methods in

improving performance and meeting client health

expectations. The trainings helped the participants appreciate

different dimensions of quality and the use of QI tools in gaps

identification. Also during Year 4, post training follow-up

mentorship and coaching were conducted in 44 HaaB health

facilities. Sites were taken through the practical facility

registration, assessment and reporting using the SQIS online

web-based platform and the use of the QI approaches and

methods to document, monitor and improve identified

implementation gaps in their documentation journals.

3.1.3. Support facility self-assessments

During the quarter, the Program supported 41 facilities to conduct self-assessments. Overall, during the

year, a total of 219 facilities in 33 districts were supported to self-assess on the online SQIS platform.

Assessed health facilities can now monitor their quality improvement progress by comparing and

Integrated QI & SQIS Trainings for HaaB2 Health facilities

QI&SQIS onsite follow up mentorship –taking health workers through the online

web-based platform



analyzing the different series of assessments they submit in the system. Health workers are also better

able to prepare for pre-licensing inspections.

During Year 4, the Program in partnership with the Intrahealth Capacity Project, printed and

disseminated over 2,000 SQIS tool kits to private health facilities and the medical regulatory

professional councils. Health facilities can now access a tool kit from the councils at the time of

registration to enable them understand their requirements at registration time. .

3.1.4. Maintain USAID/ASSIST continuous quality improvement (CQI) approaches and scale up to

other Program activities

During Year 4, the Program in collaboration with the USAID/ASSIST project scaled up quality

improvement approaches through trainings, mentorship and coaching to all partner health facilities.

Over 95% of the Program health facilities have QI teams. During the next quarter, the Program will

focus on cementing the institutionalization of QI principles and methods using best practices and lesson

learnt by engagement of the facility’s management. The purpose will be to strengthen the support and

sustainability of CQI activities in all sites through managers’ orientation to conduct Monthly QI

mentorship and coaching, sharing and learning sessions, technical specific performance review

meetings to monitor KPIs, and harvesting meetings to document best practices packages of tested QI

changes in the private sector.

3.1.5. Establish a laboratory network

During the fourth quarter, the Program continued with the process of supporting the formation and

operation of a private for-profit medical diagnostic laboratory network from amongst members of the

Uganda Medical Laboratory Technology Association (UMLTA). Since this network will follow a

franchise network strategy, the Program supported UMLTA adopt the Labnet name and branding

strategy with a goal of achieving a uniform East African Community-wide identity for qualified

independent medical laboratories.

Since Labnet is a for-profit commercial organization owned and operated by its members, the Program

supported the organization to develop a shareholding structure with Labnet members in the majority.

Minority shares were set aside for the possibility of financial investors taking an equity stake. The

Program also achieved the following during the quarter:

Drafted Memorandum and Articles of Association (Memarts) after which a meeting between the

lawyer and representatives of the interim board of Labnet Uganda was successfully held to discuss

formation, governance and registration issues prior to company registration. The following issues

were clarified in the meeting; process for allotment of shares, price per share, shareholding

structure, process of appointing a board and for how long the board will serve;

Procured a branding company to develop branding guidelines including a logo for Labnet Uganda;

Finalized the company registration process and the registration certificate will be ready by next

month; and

Completed the first round of reviews of the Standard Operating Procedures (Quality standards) for

Labnet

During Year 4, the Program conducted a training on market based approaches that covered the basic

concepts of the Making Markets Work for the Poor (M4P) approaches. This training was attended by 30

people from amongst the Program’s partners including those in the laboratory sector. The Ugandan

laboratory network draws upon experiences in Kenya where the Association of Kenya Medical

Laboratory Scientific Officers (AKMLSO) launched the Labnet network in 2015, which currently has

90 members. Labnet offers consumers of all income levels a clearly identifiable place to obtain accurate

diagnostic tests at an affordable price, with opportunities for standardizing quality, lowering prices,

mitigating competition from unregulated informal market players, and overall better health outcomes

for patients.



3.1.6. Conduct DQA across all Program health areas

Five OVC sites (Alqudus, Nankyama Foundation and Karera Ecumenical Development Organization,

Kakira Out-growers Rural Development (KORD) and International Needs Network (INN)) were visited

by MGLSD, MEEPP and the Program team for an external Data Quality Assessment & Improvement

(DQAI) exercise. The draft reports indicate strengths in the M and E structure, systems and availability

of tools. However there was limited understanding of the OVC indicators and data utilization. These

areas of improvement have been planned for the next quarter.

During the quarter, the program continued to carryout safe male circumcision (SMC) data validation

and provided on-site support in reporting. Results from validation reports indicate that all the data

verified was within the + or -3% variation and therefore no significant errors reported in VMMC data.

The program continued to put emphasis on men aged 15 – 29 years through age specific mobilization,

VMMC sensitization in Secondary Schools and use of circumcision champions.

3.1.7. Conduct Site service quality assessments using SIMS tool

The Program trained 40 frontline health workers from high volume ART and VMMC health facilities

in the use of Site Improvement Monitoring System (SIMS) to support SIMS tools application in data

collection, assessment, monitoring and remedial action for improvement. During the reporting period,

the Program conducted SIMS assessment at 25 PHP sites in quarter 1 and at 40 high volume health

facilities including VMMC implementing sites in Quarter 4. The findings were summarised in a

dashbaords that were shared with each individual health facility. The findings revealed challenges

across all health facilities in the areas of patient tracking, lack of policy guidelines on gender, patient

charter and stigma & discrimination, limited or no services for key populations, limited adolescent

services and weak laboratory systems, especially quality testing, monitoring and quality assuarance

more evidently in low volume PHPs health facilities. These challenges were addressed in subsquent

quarters 2 and 3, and the findings in the Quarter 4 assessment revealed significant performance

improvement in all technical areas though little was being done in relation to supporting services for

key populations. The Program dessiminated and oriented health workers on patient’s charter, guidelines

on stigma & discrimination, trained health workers in adolescent HIV care guidelines and distributed

job aids, in addition to supporting gender integration in health programming and service delivery.

3.2. Implement SQIS and other continuous quality improvement mechanisms

3.2.1. Resume updating the council acts through a performance based grant

During the fourth quarter, the Program conducted a

stakeholder consultation on drafting of regulations for the

Uganda Medical and Dental Practitioners’ Council, Allied

Health Professionals’ Council and Uganda Nurses and

Midwives’ Council Acts. Through the consultation, it was

agreed that regulations be drafted for both the old and

amended Acts as the processes of passing these bills by

Parliament may be longer than anticipated. The Program

also consulted the Law Reform Commission and Ministry

of Justice on the progress of the Bills and drafting of

regulations. The Program lobbied members of parliament

through their Parliamentary Forum on Quality of Health

Services in Uganda for support of the Bills when tabled

before parliament. The Program identified two champions:

Hon. Herbert Kinobere, Chair of the Parliamentary forum

on quality of health services and Hon. Michael Bukenya,

Chairman Parliamentary Committee on Health.

HF QI implemented Project sharing

Guided QI learning sessions



During Year 4, the Program established contact with the First Parliamentary Council for refinement of

the Bills prior to presentation to the Minister of Health. The Program engaged the Members of

Parliament for buy-in and identification of champions for the Amendment Bills.

3.2.2. Assist the councils to design and establish a web-based platform

During the fourth quarter, the Program facilitated trainings to equip IT staff from the respective

Councils with the web-based platform. The health professional’s registration and licensing workflow

was illustrated end-to-end for the IT staff. Also, a staff capacity assessment was undertaken and skills

divulged to the Council staff with knowledge to manage the common digital platform. By the end of

the quarter, all questions relating to the system were answered, such as: how to operationalize the

platform; where the platform should be hosted; how to sensitize the health professionals, and; what

should the platform be called. The system will be hosted via cloud and was named “The e-Health

Licensing Platform”. It is now live and available at the following URL – www.e-health.med.ug. Further

trainings of the Council staff will be done after SQIS integration.

During Year 4, the Program conducted a technical review of the web-based platform. The purpose of

the review was to streamline and harmonize all the Council’s systems so they could register, certify and

license all HRH personnel and private sector facilities. The review revealed that challenges still existed

that had slowed down the process of harmonization and streamlining of council policies and procedures

for a variety of reasons - most important among them - the Councils’ reluctance to abandon their current

practices. The Program also engaged the National Information and Technology Authority (NITA),

Ministry of Health, and each of the three councils to conduct a systems analysis. Necessary changes to

simplify, streamline and unify all Councils online procedures were incorporated. All the necessary

changes will be completed by end of October and the system re-instated and hosted on Cloud at the

same time.

3.2.3. Support continuous professional

development

During the fourth quarter, the Program printed

1,000 copies of continuous professional

development (CPD) guidelines and also provided

technical assistance to the National CPD steering

Committee to advocate for and disseminate CPD

guidelines for health professionals. The CPD

module was incorporated into the e-health licensing

platform and was illustrated to all three councils.

During Year 4, the Program revitalized the National

CPD Steering Committee which had been dormant

for many years. All three council CPD guidelines were updated and approved by each Council. The

guidelines will be useful to all medical practitioners to reflect on how their learning and development

improves the quality of care they provide to patients. Fulfillment of minimum CPD requirements will

bring about improved quality of care in the health system by ensuring that every practitioner continually

updates their knowledge and skills in their respective fields.

3.2.4. Assist Kampala City Directorate of Health Services to harmonize and field test a uniform

application for facility licensure

During Year 4, a technical review of the web-based licensure system revealed that there were still some

challenges that had slowed down the process of harmonizing and streamlining the council policies and

procedures. The key challenge was the councils’ reluctance to abandon their current licensing practices.

As a result, the current web-based version had “digitized” each Council’s old, isolated and inefficient

ways of registration and licensing instead of having one uniform application. This will be addressed

http://www.e-health.med.ug/



during Year 5 to make the system less siloed and more unified by engaging each of the Councils and

having them agree on similar indicators and attributes that do not need to be duplicated in the system.

3.2.5 Assist Kampala City Directorate of Health Services and Environment to conduct a private

provider census

During the fourth quarter, the Program in partnership with KCCA, disseminated the health facility

census findings to multiple stakeholders. Some of the fora at which KCCA disseminated these findings

included presentations during the National QI conference and the Parliamentary forum on QI task force

meeting. KCCA is currently using this data to monitor health service provision and distribution within

the Kampala region. The Program also started upon the process of designing and populating an

inventory of existing public-private partnerships (PPP’s) in health within the KCCA region.

During Year 4, the Program completed the private provider census within the Kampala region. One of

the key census recommendations was for the professional councils to use the KCCA facility census data

to improve upon the council web based platform especially the master sheet which has all facilities in

KCCA. These additions will make the web-based system more efficient as opposed to manually

inserting facility numbers. KCCA also reviewed and analyzed the facility census and service delivery

data to identify opportunities to strengthen referral between public and private sectors.

3.3. Assist private sector representatives to promote standards of care among PFP providers

3.3.1. Strengthen capacity of UHF and other private sector associations to provide services valued

to their members

During the fourth quarter, the Program supported the review of the draft five year strategic plans

developed by the Uganda Private Midwives’ Association (UPMA), Uganda Community Based

Healthcare Association (UCBHCA) and the Uganda Private Health Training Institutions Association

(UPHTIA). Once the strategic plans are completed, the associations will be better placed to fulfil their

mandates and raise extra resources from alternative sources, including donor organizations, so they can

become sustainable.

During Year 4, the Program provided support in legal, coordination and logistical services to private

health sector associations. These included the Uganda Healthcare Federation (UHF), Uganda Private

Midwives Association (UPMA), Uganda Private Health Training Institution Association (UPHTIA),

Uganda Community Based Health Care Association (UBHCA) and Mukono District Private sector

association. When this support is concluded in Year 5, the associations will have up-to-date

constitutions and all required legal documentation for them to provide more services of value to their

members such as pooled procurement.

3.3.2. Support UHF to implement strategic plan

During the fourth quarter, the Program supported UHF to write a financial proposal to the World Bank

totaling US $100,000. The purpose of the proposal was to win a grant to support UHF enroll and conduct

a self-assessment of 100 Uganda Private Midwives Association health facilities on the SQIS online

version. UHF will then verify the self-assessment reports and support the facilities to address the gaps.

Currently UHF is in final phases of signing this contract.

During Year 4, the Program supported UHF to achieve two objectives that are in the UHF Strategic

Plan (2016 - 2021). These were 1) Making UHF financially self-sustaining by financing 50% of

operational costs independently and, 2) Establishing UHF health sector working relationships. The

Program achieved the first objective by helping UHF write two proposals to the World Bank and to

Merck for Mothers which brought the UHF income for the year to a total of over UGX 700 Million. For

the second objective, the Program supported UHF to represent the private sector in the MOH TB

coordination committee and the MOH Quality Assurance and Inspection Department Committee.



3.3.3. Strengthen private sector engagement with MOH

During the fourth quarter, the Program facilitated a UHF member engagement event where all UHF

members and representatives from MOH got together to share insights and perspectives as they

reviewed UHF’s purpose and its role as a private sector voice. This meeting agreed on the future

organizational and strategic direction of UHF. The Program also sponsored six PHPs to attend the 3rd

National Quality Improvement Conference where the Program and UHF submitted and presented two

abstracts: one on the KCCA facility/provider census and the other on SQIS. In addition, UHF co-

organized the 3rd Members of Parliament Quality Improvement Forum symposium on September 28th

at Collin Hotel, Mukono. Finally, UHF represented the private sector during the 23rd Joint Review

Mission, where Program efforts to improve QI in the private sector through SQIS were recognized.

These engagements provided UHF an opportunity to ably represent and voice private sector

perspectives on the various health sector issues.

During Year 4, in order to build closer working relations with the public sector, UHF co-chaired three

MOH PPPH technical working group (TWG) meetings, attended the NHIS Taskforce meetings and

three (3) HPAC meetings. UHF also took part in and co-organized the Members of Parliament Quality

Improvement Forums meeting held on April 28th- 29th at Ridar Hotel. These interactions enabled

stronger leverage for lobbying and advocacy activities with key stakeholders that take part in these

meetings. UHF also spearheaded the formation of a stakeholder group to support the NHIS and Patients

Responsibility Bills which are crucial in achieving Universal Health Coverage in Uganda.

3.3.4. Advance the formation of a public-private sector dialogue forum

During the fourth quarter, the Program supported UHF to translate the PPPH technical working group

to a committee that doubles as a public-private sector dialogue forum. UHF is now co-chair of the new

PPPH TWG and ensures that the PPPH TWG meets at least once per month. The dialogue forum will

focus on health financing and PPP opportunities and create a shared understanding of the role of the

private health sector in Uganda. It will share ideas, demonstrate the private sector’s role in contributing

to sustainable development, offer recommendations to government from the private sector, and inspire

new public-private partnerships to overcome systemic challenges in Uganda.

During Year 4, the Program continued its efforts towards supporting the recently revived public-private

sector dialogue forum. The Program supported three PPPH TWG meetings and used these meetings to

promote the public-private sector dialogue agenda. Specifically, the Program

Identified five critical private sector stakeholders to form the core of the PPD forum. These were

UHF (who are now the co-chair of the TWG), Uganda Health Marketing Group (UHMG), Health

Partners Uganda, Uganda National Health Consumers Organization (UNHCO), and PACE Uganda.

Convened above mentioned key private sector stakeholders to determine the terms of engagement

of the PPD forum. These terms include regular monthly meetings, stakeholder involvement in

developing meeting agendas, and distribution of signed minutes amongst all stakeholders.

Presented the the draft implementation plan of the PPPH and costing of the PPPH five-year strategic

plan to PPPH TWG members.

3.4. Implement PPPHs that strengthen private sector capacity to deliver quality services

3.4.1. Develop the Ministry of Health PPPH Node’s capacity

During Year 4, the Program conducted a training on basic concepts on PPP’s in health (PPPH) and on

regional experiences in PPP’s. Participants included representatives from different social franchises,

professional associations, medical bureaus, and civil society organizations. The Program also supported

efforts towards designing and approving the PPPH Node charter. Finalization of this work was deferred

until when the PPPH structure and TWG composition is aligned to the law. This decision was because

the recommendations of the analysis of the existing structures set out in the PPPH policy proposed an



expansion in the PPPH structure within MOH. As such, the staffing plans might be more expansive than

the current structure provides for. To develop a standard Node charter therefore required aligning the

proposed new PPPH structure to the PPP law. This activity is ongoing and will concluded during the

next quarter.

The Program also continued with efforts towards the development of the PPPH implementation

guidelines and procedures. The Program validated the draft PPPH strategy and a need to develop an

Implementation Plan to operationalize the PPPH strategy was identified. The Program will provide

technical assistance to annualize and cost the strategy. During the year, the Program also trained 23

MOH/private sector staff as Trainers of Trainees in PPP’s for health.

3.4.2. Build support for the MOH to implement PPPs in health

The Program is supporting the PPPH Node to populate an inventory of existing PPPs in health within

the KCCA area and this will be finalized in Year 5. This exercise will help KCCA to define the number

and scope of PPPHs underway in the Kampala region and to move them from informal to official PPPHs

with formal agreements. To achieve this goal, this Program will assist KCCA to 1) create an inventory

of all KCCA’s PPPHs to settle the actual number of, collect minimum information on each PPPH, and

centralize the data so KCCA can track and monitor the PPPHs, 2) analyze the type and range of PPPHs

to develop a typology of PPPH models to help KCCA: a) classify PPPHs, b) standardize partnership

arrangement according to PPPH categories, and c) ide ntify trends in PPPH scopes and activities and 3)

establish policies and procedures to formalize existing PPPHs including creating legal, contractual

templates for each type of PPPH model, updating and aligning existing agreements to conform with

new templates and negotiating new agreements for PPPHs without one.

3.4.3. Form a steering committee

and conduct a private sector

assessment

During Year 4, the Program

finalized and completed the

Uganda Private Health Sector

Assessment (PSA). The Program

conducted a national dissemination

workshop and launch of the Private

Sector Assessment (PSA) report.

The PSA explores policies

supporting governance of the

private health sector; health

financing related to the private

health sector; human resources for

health; size and scope of the private

health supply chain; and private

sector delivery of key health

services including HIV/AIDS,

maternal and child health, maternal and child health, and HRH. The assessment used a representative

sample of stakeholders from the entire country ensuring urban-rural representation. Key

recommendations include: build government capacity to assure quality in a mixed health delivery

system; create financial incentives to harness the private sector; reduce economic barriers to health

access, and broker targeted partnerships to increase access to health services. A road map dubbed the

“Private Sector Blue-print” was developed to guide public-private interactions and discussions within

the sector.

The MOH further requested the Program to have the PSA findings disseminated to the wider public and

get feedback to enrich the final report for printing and adoption as a sector policy guiding publication.

These dissemination meetings kicked off during the fourth quarter and will be held at regional level

Commissioner of Health Services Planning MOH, Dr. Sarah Byakika, launching the Private Sector Health Assessment. Kampala, Uganda. February 8, 2017



targeting the Central, Western, Northern and Eastern regions - inviting 10 districts per region and at

least three representatives per district. Thereafter the PPPH Node will incorporate the feedback and

produce the final report during the next quarter.

3.4.4. Build the MOH’s PPPH pipeline

During the Year, this activity was accomplished. Please refer to activity 3.4.2 above for more details.

3.4.5. Strengthen PPPH coordination at both the central and district level

During the Year, the Program accomplished the following regarding PPPH coordination.

MOH PPPH Node organization chart/linkages at the central level, in and out of the health ministry

were developed and shared with the MOH for approval.

Designed a PPPH Node charter, a staffing plan and individual work plans and shared these with the

MOH

Completed a report on the PPPH implementation guidelines which was submitted to the MOH

PPPH Node office. The draft guidelines places focus in nine areas with the aim of reducing the

operational nature of the previously developed guidelines especially for the TCMP (Traditional and

Complimentary Medicine practitioners). The draft report was reviewed at a stakeholders’ validation

meeting in August.

Developed the terms of reference (TORs) for the development of the operating systems and

procedures for the PPPH implementation guidelines. The development of the operations manual is

awaiting approval of the implementation guidelines since it would rely on the content within them.

Developed costed activities along the four strategic areas of the 5-year PPPH Strategic Plan. The

draft plan, estimated to cost US $5 million over the five years of the PPPH Strategy, is pending a

stakeholders’ validation meeting.

The Program held two quarterly debriefing

meetings with at which it shared information on

the progress of the PPPH project. At the MOH

senior management committee meeting, the MOH

team was briefed about the overall progress of the

Program’s grant to UNACOH. In addition, the

meeting was briefed about the progress of

development of a 5-year PPPH Strategic Plan and

the development of the costed implementation

plan to operationalize the strategy. The meeting

was also briefed about the studies so far

conducted, including the “Review of the proposed

composition and TORs of the PPPH TWG” which

the SMC were informed would have an impact on

the staffing structure of the PPPH Node in the

MOH. The SMC meeting appreciated the briefing

on the PPPH project, and recommended that a

summary of key issues on the project should be

shared in the meeting of the Health Policy

Advisory Committee (HPAC). The SMC also

commended USAID for the support towards upscaling of the profiling of the Public Private

partnerships.

A cross-section of members attending the PPPH TWG meeting in Kampala. In the TWG meeting, UNACOH had the opportunity to share the draft report of the development of the combined implementation guidelines, for members to critique.



Grants management and performance

During PY4, the Program grants portfolio stood at UGX 12,930,134,363 for both Private Not-for Profit

(PNFP) and Private for Profit (PFP) grantees implementing care and treatment, and OVC interventions.

The performance level at year end was at 99.8% of all funds disbursed, while the liquidations by close

of year was at 100%. Four health systems strengthening grants were also awarded to the medical bureaus

increasing the PNFP grants portfolio to UGX 15,430,198,803.

Under the performance based approach, PHS rolled out 2 Clinical grants to Charis Health Centre and

Family Health Resource Centre, 1 PPPH capacity building grant implemented by Uganda National

Association of Community and Occupational Health, and 1 Economic strengthening grant implemented

by Child Empowering and Development Organization. PHS continued with 1 Council grant

implemented by African Centre for Global Health and Social Transformation, 1 Advocacy grant

implemented by Uganda Health Federation and 1 Community insurance grant implemented Integrated

Community Based Initiative. 9 Civil Society Organizations implemented 10 OVC grants through

partnership with the private sector1.

Managing performance based grants

Under this funding mechanism, funding decisions for quarterly disbursements are made basing on prior

agreed upon milestones delivered on quarterly basis. The first disbursement of a new grant (i.e.100%)

was made upon submission of the disbursement request by the grantee, and subsequent disbursements

depended on grantee performance as reported in each grantee quarterly report and as verified through

performance monitoring and data validation using the following score rating system:

Quarterly Weighted Average Quarterly Advance

>65% 100% of Advance Requested

41% ≤ 65% 75% of Advance Requested

≤40% Suspension of Disbursements

Improvement in the grants management process throughout the contract period was largely attributed

to the quick turnaround of the partner proposals, review and approval process, coupled with timely

submission of partner requests to Cardno home office for timely disbursements.

Compliance checks and support supervisions were routinely conducted, and data validations conducted

to determine the performance of the grantees. Overall the results of the validation exercise for grantees

indicated that they were on track. Out of 16 PFP grantees, only 1 received 75% of their disbursement

in one of the quarters and with an overall average performance of 75%. All other grantees received

100% their quarterly disbursement. Technical support in areas where gaps were identified during the

validation exercises was instantly provided.

The figures below show graphical representation of PNFP and PFP grants performance per grantee

throughout the reporting period.

1 These include Family Spirit Children Centre, Fishing Communities Initiatives, Kiyita family alliance for

Development, Kakira Outgrowers Rural development, Action for behavioral change Uganda, SOS Children’s

Village Uganda Kakira, International Needs Network, Environmental Conservation & Agricultural Enhancement

Uganda Ltd and Francois-Xavier Bagnold.



Figure 17: OVC approved grants for the period versus funds disbursed

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Figure 18: Care and treatment grantee approved grants versus funds disbursed

Figure 19: PFP grantee average percentage performance for the period October - September 2017

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Perfomance Based Grantee Average Percentage PerfomanceOct-Sept 2017



Figure 20: PFP grantee funds disbursement against budget status for the period October - September 2017

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Perfomance Based Grants Budget Vs Disbursement Oct-Sept 2017

Budgeted Amount Total Disbursed



Annex 1: PHS Performance Indicator Table, October 2016–September 2017

Performance Indicator Title ANNUAL TARGET

Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

IR1: Expanded availability of health services by program supported private service providers

Continuing to scale up high impact HIV prevention services

HIV Testing Services (HTS)

Indicator 1: Number of individuals receiving HIV Testing and Counseling (HTC) services for HIV and received their test results

352,704 79,766 76,250 92,240 86,630 334,886 94.9%

(147,022 PFP, 189,864 PNFP) Good performance at 95% of the annual target. This was as a result of site based mentorship, improved mobilization, conducting community HTC outreaches and availability of HTC kits and supplies.

Indicator 2: Total Number of Individuals Testing HIV Positive

12,536 2,328 2,645 2,792 2,463 10,228 81.6%

(4,127 PFP, 6,101 PNFP) Good performance at 81.6% of the annual target though positivity is below the national prevalence of 6.2%. Facility staff have been supported to provide Targeted HTS at high yield entry points and focus on priority and key community groups. This is likely to increase the positive yield in the next quarters.

Indicator 3: Total Number of Positives Linked into Care

5,430 1,799 2,107 2,180 2,076 8,162 150.3%

3,250, PFP, 4,912 PNFP). Linked 84.3% of the positives identified during the last quarter. Achieved 150.3% of the annual target of 5,430. Mentorship and support on use of the National Standard Operating Procedures for Linkage and Referral will continue to improve on linkage and enrollment into care.

Prevention of Mother To Child Transmission (PMTCT)

Indicator 4: Percentage of pregnant women with known HIV status

95% 97% 94.6% 100% 98% 97.3% 102.4% Good performance at 102.4% of the annual target. Support to continue being provided to staff implement the changes in the HTS guidelines for mothers attending ANC.

Indicator 5: Percentage of HIV-positive pregnant women who received antiretrovirals to reduce risk of mother-to-child-transmission (MTCT) during pregnancy and delivery

98% 72% 98.7% 95% 91% 91.3% 93.2%

Good performance at 93.2% of the annual target of 98% of HIV-positive pregnant women receiving antiretroviral to reduce risk of mother-to-child-transmission (MTCT). The staff are doing intensified follow up for missed opportunities in maternity.

Indicator 6: Percentage of infants born to HIV-positive pregnant women who were started on Cotrimoxazole (CTX) prophylaxis within two months of birth

80% 70% 91% 52.0% 89% 68.9% 86% Some of the infants born are yet to make 6 weeks when CTX is initiated.




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

Voluntary Male Medical circumcision (VMMC)

Indicator 7: Number of males circumcised as part of the voluntary medical male circumcision (VMMC) for HIV prevention program within the reporting period

45,448 5,420 9,193 20,592 16,525 51,730 114%

(30,661 PFP, 20,734 PNFP). Good performance at 113.8% of the annual target. The overall good performance in the number of men circumcised is largely attributed to the change in the TT policy to one shot on day of circumcision that resulted in improved uptake of the service. The program also conducted individual facility performance reviews with facilities that had poor performance and agreed upon approaches and strategies to scale up VMMC services. Some facilities also had budget modifications to support additional VMMC activities.

Indicator 8:Number of males circumcised surgically or by medical device that experienced at least one moderate or severe adverse event (AE)

780 49 58 95 69 271 35%

Quality services with emphasis on wound care and follow up of clients provided. This is evidenced by fewer AEs during the year that were all locally managed. Capacity will further be built on preventing and managing AEs including VMMC emergencies.

Further expanding access to Antiretroviral Therapy (ART)

HIV/AIDS Treatment

Indicator 9:Number of adults and children newly enrolled on antiretroviral therapy (ART)

10,385 1,288 1,640 1,944 1,989 6,861 66.1%

1,989 enrolled 661 PFP, 1,328 PNFP) in the last quarter. There has been a steady increment in the number of clients newly enrolled onto ART across the quarters. 6,861 (4,730 PNFP, 2,131 PFP) were enrolled during the year. The program has just concluded training of facility staff in the implementation of the new ART guidelines (on Test and Start) and this will increase the numbers in the coming year.

Indicator 10: Number of adults and children currently receiving antiretroviral therapy (ART)

43,224 34,842 36,079 37,854 38,422 38,422 89% 38,422 (11,274 PFP, 27,148 PNFP) clients on ART. The numbers are expected to steadily keep increasing with the implementation of 'Test and Start'

Indicator 11: Percentage of adults and children known to be alive and on treatment 12 months after initiation of antiretroviral therapy

89% 74% 81.5% 84.3% 80% 80.2% 90% Achieved 90% of the target of 89% retention rate. The program will continue to monitor retention and actively follow up clients to account for all clients who are enrolled on treatment.

Indicator 12: Percentage of ART patients with a viral load result documented in the medical record within the past 12 months with an non detectable viral load (<1000 copies/ml)

90% 90% 90% 92% 91% 91% 101%

Achieved 101% of the national target of 90%. The program supported and will continue to support the facilities to strengthen adherence monitoring and counselling using the Intensive Adherence Counselling Guide.




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

Sustained care and support

Clinical Care

Indicator 13: Number of HIV-positive adults and children newly enrolled in clinical care during the reporting period who received at least one of the following at enrollment: clinical assessment (WHO staging) OR CD4 count OR viral load

5,491 1,450 1,478 1,572 1,318 5,818 106.0% Achieved 106% of the annual target. The program will continue to support utilization of linkage and referral SOPs with an emphasis on active follow-up and linkage.

Indicator 14: Number of HIV-positive adults and children who received at least one of the following during the reporting period: clinical assessment (WHO staging) OR CD4 count OR viral load

64,445 39,626 38,520 39,976 39,319 39,319 61.0% 11,494 PFP, 27,825 PNFP) Numbers in care are expected to increase at most of the sites following the implementation of 'Test and Start'.

Tuberculosis (TB)/HIV

Indicator 15: Percentage of registered new and relapse TB cases with documented HIV status

90% 80% 68.9% 92.7% 80% 78.7% 87% Performance expected to improve with continued guidance in TB/HIV documentation provided to Facility TB staff

Indicator 16: Percentage of HIV-positive new and relapsed registered TB cases on ART during TB treatment

100% 93% 91.3% 96.4% 97% 97.3% 97% Support provided during the quarter for TB/HIV implementation improved service implementation.

Indicator 17: Percentage of PLHIV newly enrolled in HIV clinical care who start isoniazid preventative therapy (IPT)

30% 8.3% 1.7% 5.8% 7.6% 7.8% 26% Few authorized IPT implementing facilities under PHS and in the country because of limited quantities/stock. The current stock can't meet the demand from eligible clients in the country.

Indicator 18: TB treatment outcomes among registered new and relapsed TB cases who are HIV-positive

100% 73% 71.2% 72.8% 68% 71.4% 71.4%

Treatment success rates stagnated at around 71% during the year. The program will continue supporting facilities to follow up all clients, conduct outcome evaluations and improve documentation using QI approach.

Indicator 19: Percentage of PLHIV in HIV clinical care who were

90% 88% 88.6% 94.8% 97% 97% 108% Mentorship and support for TB screening and documentation will continue to be provided to further improve performance.




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

screened for TB symptoms at the last clinical visit

Nutrition

Indicator 20: Percentage of People Living with HIV (PLHIV) in care and treatment who were nutritionally assessed

100% 78% 86.46% 94.3% 94% 94.0% 94% Proportion of PLHIV assessed for malnutrition improved across quarters following provision of assessment tools and a training in NACS for PNFP facility staff who hadn't yet received the training.

Indicator 21: Proportion of clinically undernourished PLHIV who received therapeutic or supplementary food

80% 46% 21.8% 81.8% 98% 52.6% 66%

Proportion of undernourished clients receiving supplementary foods kept improving across quarters following the training that equipped facility staff on how to identify and recommend food to malnourished clients.

Malaria

Indicator 22: Number of pregnant women receiving two or more doses of IPT for malaria

24,600 4,361 4,511 4,886 5,417 19,175 77.9%

(8,297 PFP, 10,878 PNFP). Achieved 78% of the annual target. Performance increased steadily across quarters following a training in 'Malaria in pregnancy' was conducted and equipped facility staff to identify and provide IPT to eligible pregnant mothers.

Family Planning

Indicator 23: Percentage of HIV service delivery points supported by PEPFAR that are directly providing integrated voluntary family planning services

95% 87.3% 46.5% 80.3% 80.3% 73.6% 77.5%

Integrated FP were provided at 51 of the 71 facilities. However the program conducted FP training to bring on board additional facilities providing FP services.

Indicator 24: Number of new acceptors to FP registered at health service outlets

30,000 3,581 6,588 5,883 8,643 24,695 82.3% Number of new acceptors to FP increased particularly in last quarter as a result of support in FP commodities at facilities and capacity building in LARC including postpartum FP.

Indicator 25: Couple Years Protection (CYP) in USG supported programs

14,000 43,019 43,019 307.3% The number of FP users increased with many clients receiving long term methods (IUD and Implants) that have a bigger impact on protection against pregnancy.

Maternal and Child Health (MCH)

Indicator 26: Percentage of mothers attending at least four antenatal care (ANC) visits during pregnancy

70% 16.4% 9.5% 17.1% 13.2% 14.1% 20% Most of the mothers come late to the facilities for safe delivery when it’s too late to attend many times.




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

Sustained care and support for orphans and other vulnerable children (OVC)

Orphans and Vulnerable Children (OVC)

Indicator 27: Number of active beneficiaries served by PEPFAR OVC programs for children and families affected by HIV/AIDS

45,707 40,174 44,838 46,572 39,058 46,572 101.9% 46,572 (31,898 PNFP and 14,674 PFP) OVC were served during the year

Indicator 28: Number of active beneficiaries receiving support from PEPFAR OVC programs to access HIV services

23,490 4,097 15,955 29,120 11,127 29,120 124.0% (25,707 PNFP, 3,413 PFP). These are beneficiaries who were supported either to test for HIV or access care and treatment during the year

Indicator 29: Number of OVC beneficiaries who know their HIV status and have self-disclosed HIV status to OVC implementing partners

22,854 12,624 25,777 30,752 35,613 35,613 155.8% 35,613 OVC on the program know their status and the positives are supported to access care and treatment while the negatives continue to receive HIV prevention messages.

Improving availability of human and financial resources to support service delivery

Financing

Access to Finance

Indicator 30: Percentage of Development Credit Authority ( DCA) bank loan portfolio held by first time new private health provider borrowers with the DCA bank

40% 7.1% 8.4% 21% 0% 21% 21%

This target has been skewed by Ecobank's 0% utilization in this borrower category compared to 35% for Centenary. Ecobank’s poor performance is due to:-Bank’s high risk aversion attitude, Management and staffing problems, Limited rural branch network, Over centralization of the bank’s credit function at head office, Failure to leverage DCA guarantee to relax collateral requirements, Restrictive requirement of audited books for all loans,

SME vs. corporate lending, Lack of clear strategy to lend to female owned healthcare businesses.

Indicator 31: Overall utilization of the DCAs for Centenary Bank

100% 77.5% 79.9% 81.6% 83.2% 83.2% 83.2%




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

Indicator 32: Overall utilization of the DCAs for Ecobank

40% 14.5% 17.5% 17.5% 17.5% 17.5% 43.7%

Indicator 33: Number of relationships established with banks (DCA & non DCA)

16 4 4 0

3

11 69%

Indicator 34: Percentage of successful loan applications from rural private health providers outside the central region with both DCA banks

58% 49.5% 48.6% 43.9% 36% 44.5% 76.7%

IR2: Increased affordability of private health services and products

Indicator 35: Reduction in sales price of essential health medicines, services, and commodities

6% 10% 10% 166.7%

During Year 4, the Program continued to monitor trends in medicine prices in target districts to track price trends. Following an awareness campaign on rational use of medicines and disseminating essential medicines prices, a July assessment in one of the target districts (Jinja) revealed that 15 PHPs were selling ACTs between UGX 3500 - 4500 and only four facilities were still selling ACTs in the range of UGX 5000 – 6000.

Considered the most conservative difference from the figures above i.e. [(5,000 – 4,500) / 5,000] X 100%

Indicator 36: Number of groups (such as VSLAs) in which new health service products are implemented

120 0 0 0 70 70 58.3%

During Year 4, the Program targeted 120 VSLA groups in four districts (Jinja, Wakiso, Sheema and Rukungiri) to implement health service products. By the end of the year, 70 VSLA groups had endorsed policies for saving for health and were enrolled in community health insurance products within their respective communities.

Indicator 37: Number of partnership agreements established with private sector pharmaceutical firms/franchises

2 0 0 0 2 2 100%

Signed an MOU with Joint Medical Stores to promote health savings and Nilkanth Group of Pharmacies.

Improved governance and management of services

Governance

Indicator 38: Number of health facilities with functional health facility boards and committees

22 17 17 77.3% 17 health facilities have functional health facility boards and committees (that meet regularly and document their proceedings)

Indicator 39: Number of private health facilities that have

22 19 19 86.4% 19 facilities out of the targeted 22 have strong involvement of communities and patients in their planning and provision of health




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

participation of patients and communities in activity implementation

services. This is mainly through the suggestions boxes, community health days and use of VHTs for community mobilization and health promotion.

Indicator 40: Number of health facilities with properly functioning accounting systems

22 19 19 86.4% 19 facilities out of the targeted 22 have functioning accounting systems and have been efficiently and effectively managing grants given to them.

Management

Indicator 41: Percentage of private health facilities reporting on time in the DHIS2

80% 98.6% 98.6% 100% 100% 100.0% 125%

All the health facilities are reporting timely in the DHIS2. However two sites lack entry screens for Care and Treatment data (HMIS 106a). We have engaged the MOH to activate them to enable complete reporting.

Indicator 42: Proportion of private health facilities generating strategic information and using it for planning, organization and management of health services within their facilities

80% 77.3% 100% 100% 100% 100% 125.0% All the 22 targeted facilities are using the information to inform targets during planning and when ordering for supplies.

Indicator 43: Number of private health facilities with the capacity in use of information and communications technology (ICT) for improved monitoring, evaluation and decision making

22 0 0 17 22 100% 100% All the 22 targeted facilities have computer for data management and are supported to analyze data and generate information to use for planning and decision making.

Coordination

Indicator 44: Number of private health facilities that formally participate in district planning, or decision-making or other activities

22 17 17 77.3% Most of the targeted facilities work well with the district structures and participate in all the key health related events including performance reviews, data cleaning meetings.

Indicator 45: Existence of a functional faith-based health body serving as a platform for better health advocacy, resource mobilization and stakeholder engagement

1 0 0 0.0%

Draft concept paper was shared with medical bureaus for their input before it is shared with other stakeholders. This is to promote buy-in and ownership of the process by the medical bureaus. The Program will elicit more input from other stakeholders in the first quarter of PY5.




Oct -Dec 2016

Jan-March 2017

April- June 2017

July-September 2017

TOTAL %age Achieved

Comments

IR3: Improved quality of private health sector facilities and services

Improved quality of health services

Indicator 46: Number of health facilities that administer the self-regulatory quality Improvement system (SQIS) tool at least once a year

22 58 58 263.6% PHS trained all the 71 facilities in SQIS and 58 were supported to administer SQIS during the year.

Indicator 47: Number of health facilities that have integrated quality improvement (QI) in service delivery

22 22 22 100.0% All the 22 targeted facilities were trained in QI and supported to integrate QI in service delivery. The other 49 PFP supported facilities trained were followed up to ensure QI integration in service delivery.

Indicator 48: Percent of private service outlets offering health services according to national standards

95% 100% 100% 100% All the supported sites meet the minimum standards and follow the national policies and guidelines.

Indicator 49: Number of health facilities with functional facility-community linkage systems

22 18 18 82% 18 of the 22 targeted facilities have strong community components with functional referral linkages.

Indicator 50: Medical councils with improved capacity to perform their oversight functions

4 0 0 0 3 3 75%

Throughout Year 4, the Program engaged and supported three out of four professional medical councils. The Pharmacy Council, is still facing some institutional challenges and is yet to operate at the same level as the other three.

Indicator 51: Number of health policies, reforms or administrative procedures towards creating a more supportive environment for the private health sector drafted, submitted for public/stakeholder consultation or adopted

5 4 0 0 2 6 120%

These include the following documents: 1) Analysis of other country PPP’s, 2) Analysis of the existing PPPH structure set out in the PPPH policy, 3) PPPH Implementation guidelines, 4) Implementation Plan for the PPPH Strategy, 5) Review of the composition of the PPPH technical working group, and 6) Report on the alignment of the proposed composition of the PPPH – TWG to the PPP Law and PPPH Policy

Indicator 52: Number of public-private partnership (PPP) for health project proposals drafted and submitted for review to MOH in line with the PPP’s project cycle in the health sector

2 0 0 0 0 0 0%

The Program’s grantee supporting this activity experienced some challenges specifically – the long bureaucratic processes within the MOH delaying the onset of the work as it was always a challenge getting the input of key MOH stakeholders. So this activity was started upon in Quarter 4 and will be completed in Quarter 2 of Year 5.



Annex 2: Success Story

Improving Business at Pikwo Medical Centre in Gulu

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A small laboratory at one of the main branches of Pikwo Medical Centre in Gulu district.

By supporting the growth of viable and sustainable business opportunities for private providers, USAID’s Uganda Private Health Support Program helps fuel the overall expansion of the healthcare industry.

The BDS team provides training to private for profit (PFP) and private not for profit (PNFP) providers to strengthen business management skills. This helps health facilities operate more efficiently and gives them the tools to obtain financing and thereby to grow and improve services

Kenneth Odong’s employees, below (on the next page), at the counter of his facility.

The USAID/Uganda Private Health Support Program is taking a

variety of approaches to expand the availability of services,

increase their affordability, and improve quality in the private

sector. An important component of this is strengthening private

health businesses by expanding access to financing (A2F) and

providing business development services (BDS). At least half of

Uganda’s health care needs are met by the private health care

sector through private-for-profit (PFP) health facilities which are

particularly popular for their accessibility, medicines availability,

shorter waiting times, and higher perceived quality of service.

In Gulu district, Kenneth Odong, the proprietor of Pikwo medical

Center says that the population is large enough to keep several

health facilities in business. His health facility has been in operation

since July 2011.

“We are in Kanyagoga in Badege division of the four divisions in

Gulu. It is one of the more heavily populated areas on Gulu.

However, we are surrounded by many health facilities i.e. two

hospitals as well as IMC and the regional referral hospital. But

being a private facility gives us advantages that larger facilities

cannot provide e.g. faster and more friendly service, as well as

nearly no queues to deal with for patients. We started smaller than

we are right now but by 2013, we had expanded to our current size,

and we offer a range of services, including a laboratory with over

20 different tests, general consultation, investigations, and

comprehensive family planning – long and short term,” – Kenneth

Odong, Pikwo Medical Centre (August 2017)

Despite the advantages that these private health facilities offer to

the populations they serve, they face many of the same constraints

in accessing financing as do other small businesses in Uganda.

When it comes to supply, financial institutions see a much higher

perceived risk in lending to them. USAID and SIDA’s

Development Credit Authority (DCA) reduces that risk by

providing technical assistance to the DCA partner banks and

working with non-DCA banks to develop pipelines of loan deals

with the private health sector. The Program is working with

Centenary Bank, Ecobank and DFCU bank.

In 2016, Kenneth Odong secured a loan worth US $4,000 from

Centenary Bank to increase the capacity of his health facility. With

the loan, he was able to open up a second unit 15 km away from his

facility. This new unit now serves an average of 10 – 15 people per

day.



“When we went for training in Lira, the Program staff spoke to us

about what we could do to access financial support. As soon as I

returned to Gulu, I began to visualise how I could move on from

where I was and how I could access the financial support. The

Program linked me to the Credit Manager of Centenary Rural

Development Bank. Within a short time, we were able to get the

support. While busy with this process, I also began looking for a

new location for a second facility that could house a maternity

section.” – Kenneth Odong, Proprietor of Pikwo Medical Centre,

(August 2017)

Beyond linking Health Care Businesses (HCBs) to financial

institutions, the Program also provides critical training for facility

owners in order for them to effectively and efficiently run their

health facilities. Most HCBs have poor business practices due to

lack of skilled managers. Mr. Odong has benefited from the

program by expanding his services, improved his accountability,

and financial systems, and was able to earn additional income.



USAID/UGANDA PRIVATE HEALTH SUPPORT PROGRAM

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